UNIVERSITY  OF  CALIFORNIA 
AT   LOS  ANGELES 


GIFT  OF 

C.   A.   Lindquist 


HIIVATE  LIBRARY  OF 
g  A,  JJNDQUIST,  M.D. 


LECTURES  ON 
DIETETICS 


BY 

MAX  EINHORN  M.  D. 

Emeritus  Professor  of  Medicine  at  the  New  York  Postgraduate 

Medical  School  and  Hospital;  Visiting  Physician  to  the 

Lenox  Hill  Hospital,  New  York 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1922 


Copyright,  1922,  by  W.  B.  Saunders  Company 


MADE  IN  U.   8.  A. 

PRESS  OF 
W.  B    MUNDER8  COMPANY 

PHILADELPHIA 


TO 

THE  MEMORY  OF  HIS  DEAR  AND  HIGHLY  ESTEEMED  FRIEND 

COLONEL  OLIVER  HAZARD  PAYNE 

this  book  is  respectfully  dedicated,  in 

recognition  of  his  great  devotion 

to  the  art  of  medicine  and 

to  higher  education. 


v 


V 

KT> 


PREFACE 

IT  gives  me  satisfaction  that  the  first  edition 
of  my  Lectures  on  Dietetics  (delivered  at  the 
New  York  Postgraduate  Medical  School  and 
H  ospital)  has  been  exhausted,  and  a  new  issue 
required.  The  present  volume  has  been  doubled 
in  size,  so  that  it  is  almost  a  new  book.  Nine 
new  chapters  have  been  added,  namely: 

V.  The  Care  of  Digestion;  VI.  The  Care  of 
Digestion  for  the  Soldier;  IX.  The  Dietetic 
Management  and  the  Allen  Treatment  of  Dia- 
betes Mellitus;  X.  The  Dietetic  Management  of 
Gout;  XI.  The  Diet  in  Diseases  of  the  Kidneys; 
XIII.  The  Diet  in  Operative  Cases;  XIV.  Sub- 
cutaneous and  Rectal  Alimentations;  XVI. 
Indications  for  Artificial  Nutrition;  XVII. 
Preparation  of  Food  for  Invalids  (The  Diet 
Kitchen) . 

The  reader's  pardon  is  asked  for  some  repeti- 
tions in  the  text,  due  to  the  fact  that  some  of  the 
incorporated  lectures  have  been  delivered  at 
different  periods  of  time  and  not  as  a  continuous 


8  PREFACE 

course.  The  points  mentioned  are,  however, 
usually  of  importance  and  will  by  repetition 
make  a  more  lasting  impression  and  thus  perhaps 
be  of  greater  use. 

It  is  hoped  that  the  present  book,  like  its 
predecessor,  will  contribute  toward  the  spread 
of  knowledge  of  Dietetics  in  this  Country. 

MAX  EINHORN. 

NEW  YORK  CITY, 
August,  1922. 


CONTENTS 


LECTURE  I 

PAGE 
THE  PRINCIPLES  OF  DIET  AND  NUTRITION 11 

LECTURE  II 

THE  DIGESTIBILITY  OF  FOODS,  AND  THE  DIET  IN  HEALTH  AND 

ACUTE  DISEASES 30 

LECTURE  III 

THE  DIET  IN  ACUTE  DISEASES  OF  PROLONGED  DURATION  AND  IN 
CHRONIC  DISEASES 48 

LECTURE  IV 

THE  DIET  IN  CHRONIC  AFFECTIONS  OF  THE  DIGESTIVE  TRACT 

(Continued) 66 

LECTURE  V 
THE  CARE  OF  DIGESTION 86 

LECTURE  VI 

THE  CARE  OF  DIGESTION  FOR  THE  SOLDIER 94 

LECTURE  VII 
THE  DIETETIC  TREATMENT  OF  CHRONIC  DIARRHEAS 99 

LECTURE  VIII 

THE  DIETETIC  TREATMENT  OF  DIABETES  MELLITUS 110 

LECTURE  IX 

THE  DIETETIC  MANAGEMENT  AND  THE  ALLEN  TREATMENT  OF  DIA- 
BETES MELLITUS 120 

9 


10  CONTENTS 

LECTURE  X 

PAO» 

THE  DIETETIC  MANAGEMENT  OF  GOUT 147 

LECTURE  XI 
THE  DIET  IN  THE  DISEASES  OF  THE  KIDNEYS 157 

LECTURE  XII 
DIET  REGIMES 169 

LECTURE  XIII 
THE  DIET  IN  OPERATIVE  CASES 183 

LECTURE  XIV 

SUBCUTANEOUS  AND  RECTAL  ALIMENTATIONS 189 

LECTURE  XV 
DUODENAL  ALIMENTATION 198 

LECTURE  XVI 

INDICATIONS  FOR  ARTIFICIAL  NUTRITION 211 

LECTURE  XVII 

PREPARATION  OF  FOOD  FOR  INVALIDS  (THE  DIET  KITCHEN)  .   .  222 

INDEX  .  .  233 


LECTURES  ON  DIETETICS1 


LECTURE  1 
THE  PRINCIPLES  OF  DIET  AND  NUTRITION 

I  propose  to  give  a  few  lectures  on  the  sub- 
ject of  diet.  Diet  plays  so  important  a  part  in 
health  and  disease  that  every  physician  should  be 
well  informed  on  all  points  pertaining  to  it.  It 
should  really  form  the  basis  of  every  medical 
study.  It  is  the  A,  B,  C  of  medicine.  We 
cannot  live  without  food  and  we  cannot  treat 
anyone  without  a  certain  dietary;  and  if  we 
understand  all  the  relations  of  diet  a  great  deal 
can  be  accomplished  by  it  alone  in  the  treatment 
of  disease,  without  the  aid  of  medicine.  Diet 
comprises  all  the  questions  relating  to  food,  and 
food  forms  the  basis  of  all  animal  life.  Food 
contains  all  the  substances  found  in  the  living 
organism,  because  the  body  develops  upon  it; 

1  Lectures  I,  II,  III  and  IV  on  Dietetics  have  been  delivered  at  the 
Postgraduate  Medical  School  and  Hospital  and  have  appeared  in  the 
Postgraduate  Journal  of  July,  August,  September  and  October,  1913. 

11 


12  LECTURES  ON  DIETETICS 

it  grows  up  from  the  little  baby  to  the  big  organ- 
ism. Nothing  is  added  to  the  body  excepting 
what  is  derived  from  the  food. 

On  the  other  hand,  food  contains  only  the 
substances  found  in  the  earth.  Everything  that 
we  eat,  animal  or  vegetable,  originated  in  the 
soil  under  one  form  or  another.  That  means 
that  whatever  we  have  in  our  bodies  comes  from 
the  earth.  The  Bible  says:  "From  earth  you 
are  made  and  to  earth  you  go."  Nowadays  we 
speak  of  the  different  elements  found  in  the  body. 
We  have  analyzed  the  latter  and  know  that  there 
exist  the  most  varied  substances:  carbon,  nitro- 
gen, hydrogen,  oxygen,  calcium,  magnesium, 
iron,  phosphates,  sulphur,  etc.;  but  in  the  end 
the  old  philosophers  were  right.  If  we  should 
take  earth,  even  if  we  have  all  the  elements, 
carbon,  calcium,  phosphate,  etc.,  we  could  not 
accomplish  anything  with  it,  but  after  these 
substances  have  been  changed  by  living  matter 
and  developed  in  the  forms  in  which  they  exist 
in  either  animals  or  plants  then  it  is  fit  for  our 
organism.  It  has  first  to  undergo  this  radical 
change  through  living  matter. 

Thus  far  we  have  not  been  able  to  accomplish 
these  changes  artificially ;  that  is,  we  cannot  put 


PRINCIPLES  OF  DIET  AND  NUTRITION    13 

inorganic  matter  together  so  as  to  bring  it  into 
life.  We  require  another  living  medium  to 
accomplish  this  change.  Every  living  cell  must 
originate  from  another  one.  So  living  plants 
develop  from  the  seed  into  plants.  There  must 
first  be  something  that  is  alive  to  bring  forth 
new  life.  We  know  nothing  yet  of  how  inorganic 
matter  develops  into  an  organic  being.  It  may 
be  that  the  great  chemists  and  physiologists  think 
it  originated  of  itself,  but  we  do  not  know  about 
that  for  the  present.  So  far  as  we  can  tell, 
nothing  is  developed  of  itself,  but  every  animate 
being  is  developed  from  some  living  individual. 
Our  food,  then,  consists  of  either  animal  or 
vegetable  matter.  We  find  some  nations  living 
principally  on  animal  diet,  and  some  animals 
living  on  animal  food  exclusively;  others  live  on 
vegetable  material  alone,  and  some  nations 
live  principally  on  vegetable  food.  That  shows 
that  either  of  the  two  is  feasible, — that  persons 
can  live  either  on  vegetable  food  alone  or  on 
animal  food  alone.  If  one  should  ask  which  is 
the  better  way,  it  is  generally  admitted  that  a 
mixed  diet  is  the  best  for  mankind.  It  has  been 
shown  that  those  nations  which  subsist  on  a 
mixed  diet,  taking  both  animal  and  vegetable 


14  LECTURES  ON  DIETETICS 

foods,  have  accomplished  most  in  the  way  of 
progress.  Those  nations  which  live  exclusively 
on  animal  diet,  such  as  the  Esquimaux,  or  the 
peoples  to  the  far  south  where  vegetable  material 
is  rare  and  who  live  almost  exclusively  on  the 
fish  and  animals  which  they  hunt  and  kill  have 
not  accomplished  very  much  in  the  way  of  prog- 
ress. On  theother  hand,  the  peoples  of  India, 
China,  and  Africa  live  mostly  on  a  vegetable  diet, 
and  these  nations  have  not  accomplished  very 
much  either,  in  the  way  of  progress.  It  is 
possible  to  live  in  either  way,  but  as  a  whole, 
physiologists  have  decided  that  a  mixed  diet, 
combining  the  two  forms  of  food  material,  is  the 
best  to  develop  the  mental  faculties  to  the 
highest  degree. 

It  has  always  been  known  that  you  cannot 
live  without  food ;  if  you  do  not  take  in  food,  the 
body  loses  weight,  and  finally  dies;  but  until 
recent  years  not  much  has  been  known  of  the 
exact  amount  of  food  required  by  nature  to 
maintain  life  and  to  keep  the  body  in  good  con- 
dition. The  amount  is  almost  mathematically 
prescribed,  and  in  recent  years  this  amount  has 
been  determined.  This  has  been  learned  as 
follows:  First,  it  has  been  determined  in  a  gen- 


PRINCIPLES  OF  DIET  AND  NUTRITION   15 

eral  way  how  much  food  grown  persons  require. 
It  is  noted  how  much  one  person,  a  second,  and 
a  third  eat  for  breakfast,  dinner,  and  supper. 
This  is  carefully  written  down,  and  then  the 
average  amount  consumed  is  calculated,  and 
so  we  know  about  what  amount  of  food  is  re- 
quired by  normal  persons  in  health.  That  gives 
a  fair  indication  of  how  much  is  needed. 

Now,  before  going  to  the  amounts  required,  I 
will  say  a  few  words  about  the  different  classes 
of  food.  While  every  diet  must  contain  all  the 
elements  necessary  for  life,  the  food  has  been 
divided  into  three  large  classes,  because  they  all 
contain  more  or  less  of  the  elements  necessary 
for  life.  These  three  groups  are  the  proteins, 
carbohydrates,  and  the  fats.  Among  these  are 
also  found  the  so  called  "vitamines,"  contained 
in  milk,  eggs,  cereal,  green  vegetables,  and  fruits. 

Ejkmann,1  C.  Funk,  Th.  B.  Osborne,2  Lafay- 
ette B.  Mendel,3  Hess4  and  Goldman  have  done 
meritorious  work  along  the  vitamines  and  their 
relation  to  deficiency  diseases.  While  the  exact 
chemical  composition  of  the  vitamines  has  not, 

1  Ejkmann:  Virchow's  Arch.,  1897, 148,  p.  528. 

2  Th.  B.  Osborne:  N.  Y.  State  Journal  of  Medicine,  July,  1920. 
3L.  B.  Mendel:  N.  Y.  State  Journal  of  Medicine,  July,  1920. 
4  Alfred  Hess:  N.  Y.  State  Journal  of  Medicine,  July,  1920. 


16  LECTURES  ON  DIETETICS 

as  yet,  been  established,  they  are  divided  into 
the  following  3  varieties: 

1.  The  fat  soluble  A.  vitamine  (or  the  antira- 
chitic  factor),  contained  principally  in  butter, 
the  maize  kernel;  carrots;  sweet  potatoes. 

2.  The    water  soluble  B.   vitamine    (or   the 
antineuritic  factor),  contained  in  yeast,  beans, 
cabbage,   cane   sugar,   yolk   of   eggs,   oranges, 
lemons,  grape  fruit. 

3.  The   water   soluble   C.   vitamine    (or   the 
antiscorbutic  factor)  contained  in  cabbage,  toma- 
toes, oranges,  and  milk. 

All  foods  contain  one  or  two,  or  three  of  the 
above  designated  substances,  namely  protein, 
carbohydrate,  and  fat.  In  order  to  find  out  the 
amount  of  food  necessarily  required  for  living, 
the  physiologists  have  calculated  how  much  of 
these  three  different  classes  we  require,  not  saying 
how  much  bread,  meat,  potatoes,  etc.,  but  how 
much  albumin,  how  much  carbohydrate,  or  how 
much  fat  is  required  for  a  grown  person  each 
day.  It  has  been  found  that  a  grown  person 
uses  up  each  day  about: 

120  gm.  of  albumin  =  oz.  IV 

500  gm.  of  carbohydrate  =  oz.  XVII. 
60  gm.  of  fat  =  oz.  II. 

to  3  quarts  of  water. 


PRINCIPLES  OF  DIET  AND  NUTRITION    17 

Besides  these  three  essentially  nutritive  sub- 
stances we  utilize  condiments  and  some  alkaloid 
and  alcoholic  beverages  (accessory  foods).  The 
condiments  (pepper,  table  salt,  onion,  mustard, 
cinnamon,  nut  meg  etc.)  serve  to  increase  the 
taste  of  the  food  and  make  it  more  savory. 
The  latter  (coffee,  cocoa,  tea,  beer,  wine,  etc.) 
exert  a  stimulating  effect  and  diminish  the 
depressing  act  due  to  the  process  of  digestion. 
While  the  alkaloidal  substances  (theobromin, 
caffein  (trimethylxanthin)  are  as  such  without 
nutritive  value,  the  alcohol  must  be  counted  as 
a  nutritive  substance.  It  furnishes  7  Cal.  per  1 
gm.  If  not  taken  in  high  concentration  and  in 
too  large  quantities  it  often  helps  nutrition, 
especially  in  diseased  states. 

Water  contains  many  mineral  ingredients  not 
found  in  the  food.  While  protein  must  exist 
in  the  food  which  any  individual  requires  for 
living,  in  some  way  or  another,  and  cannot  be 
dispensed  with,  either  the  carbohydrate  or  the 
fat  can  be  omitted  without  much  injury.  This 
is  to  say,  one  of  these  groups  can  replace  the 
other  without  injury  to  the  individual  for  a  while, 
but  the  albumin  is  essential.  The  reason  for 
that  is  that  the  protein  is  the  foremost  substance 


18  LECTURES  ON  DIETETICS 

in  the  body.  Any  tissue  that  is  used  requires 
albumin  to  build  it  up  again.  The  fat  which  is 
taken  in  helps  to  build  up  the  organism;  it  also 
produces  heat.  Heat  is  also  furnished  by  the 
other  substances,  by  the  protein  and  the  carbo- 
hydrates, but  as  a  tissue  builder  the  protein  is 
necessary.  From  protein  the  organism  can 
make  glycogen,  fat,  or  muscle,  but  the  body 
cannot  make  protein  out  of  the  carbohydrate  or 
the  fat.  That  is  why  protein  is  the  most  essen- 
tial substance. 

Now  the  physiologists,  especially  Rubner — 
who  was  here  not  long  ago — who  has  made  a 
great  many  studies  and  deserves  to  be  remem- 
bered, have  tried  to  ascertain  in  what  degree 
these  substances  can  replace  each  other,  and 
found  that  they  do  it  corresponding  to  the 
amount  of  heat  which  they  develop.  Every 
kind  of  food  taken  into  the  body  is  oxidized  in 
the  system.  We  take  in  oxygen  with  the  air, 
and  the  nutritive  substances  become  oxidized. 
The  more  carbon  a  special  kind  of  food  con- 
tains, the  more  oxygen  it  can  bind.  The  more 
carbon  in  the  food,  the  more  heat  it  can 
develop  in  burning  up.  The  burnt  up  or 
oxidized  compounds  leave  the  body  in  the 


PRINCIPLES  OF  DIET  AND  NUTRITION   19 

form  of  CO2  and  H2O,  through  the  lungs 
and  kidneys. 

It  has  been  found  that  one  gram  (15  grains) 
of  food  material,  if  oxidized  (burnt  up)  develops 
a  certain  amount  of  heat.  I  will  explain  how 
that  is  calculated.  It  has  been  arranged  by  the 
scientists  to  measure  heat  in  this  way :  The  idea 
is  to  know  exactly  how  to  estimate  the  heat. 
They  have  agreed  to  take  as  the  measurement 
for  one  heat  unit  the  amount  of  heat  which  is 
sufficient  to  increase  the  temperature  of  one  cubic 
centimeter  of  water  (16  grains)  1  degree  Celsius. 
This  is  also  designated  as  a  small  calorie  (cal.). 

In  speaking  of  the  heat  values  of  food,  how- 
ever, we  use  great  heat  units,  or  great  Cal. 
That  means  the  amount  of  heat  which  is  suffi- 
cient to  raise  1  liter  (1  quart)  of  water  1  degree 
C.  Returning  to  the  food  values,  it  has  been 
found  that  one  gram  of  protein  is  sufficient  to 
develop  4.1  Cal.  In  speaking  of  food  calories, 
we  do  not  say  "great  heat  unit,"  or  great  Cal., 
but  we  mean  that.  It  is  written  Cal. 

Protein,  1  gm.  develops 4.1  Cal. 

Carbohydrate,  1  gm.  develops.  .  .   4.1  Cal. 
Fat,1  1  gm.  develops 9.3-9.5  Cal. 

1  See.:  C.  A.  Ewald:  Diat  und  Diatotherapie.     Berlin,  1915,  p.  5202. 


20  LECTURES  ON  DIETETICS 

Notice  that  the  fat  develops  more  than  double 
the  amount  of  heat,  as  compared  with  the  others. 

The  way  foods  should  represent  each  other 
is  by  "their  caloric  value,  excepting  that  we  cannot 
eliminate  protein.  A  certain  amount  of  protein 
must  be  in  any  food, — but  we  can  combine 
protein  with  carbohydrate  (as  present  in  most 
vegetable  foods),  or  we  can  have  protein  and  fat 
as  represented  by  animal  foods.  If  we  should 
have  someone  live  on  protein  and  fat,  we  would 
say  that  the  fat  should  be  less  than  half  the 
amount  of  carbohydrate  required,  for  it  contains 
so  many  more  heat  units. 

Now  it  has  been  found  that  a  man  requires 
for  one  day  about  2400  calories  or  on  an  average 
30-40  Cal.  per  kilo  an  hour. 

A  man  doing  a  considerable  amount  of  work 
ordinarily  consumes  about: 

Caloric  value 

120  protein  =  120  gm.  X  4.1  =    492.0 

60  fat  =    60  gm.  X  9.5  =    570.0 

500  carbohydrate  =  500  gm.  X  4.1  =  2050.0 

3112.0 

It  has  been  found  generally  that  a  grown 
person  requires  about  2500  heat  units  each  day, 
or  food  which  develops  that  number  of  heat 


PRINCIPLES  OF  DIET  AND  NUTRITION   21 

units,  when  doing  a  moderate  amount  of  work. 
If  he  works  hard,  he  requires  more,  3000  calories, 
or  more.  If  he  is  in  bed,  he  requires  less.  I 
have  found  that  a  patient  in  bed  requires  much 
less;  he  can  exist  on  1800  heat  units  without 
losing  much  flesh. 

Smaller  organisms  require  more  heat  units 
per  kilo  weight.  This  is  due  to  their  proportion- 
ately increased  surface  ratio,  which  increases 
the  loss  of  heat.  Infants  require  more  than 
double  the  amount  of  calories  per  kilogram 
weight  of  the  grown.  This  must  be  ascribed  to 
the  comparatively  larger  surface  of  the  young 
and  the  act  of  growing.  According  to  Heubner 
and  Rubner1  the  newborn  (from  the  2nd  to  the 
18th  week)  consumes  100  Calories  per  kilo  a  day, 
later  somewhat  less.  An  artificially  fed  infant 
requires  120  Cal.  per  kilo  a  day. 

Increased  work  requires  an  increase  of  food. 
The  latter  must  always  be  much  greater  than 
the  heat  equivalent  of  the  actual  work  done. 
Usually  about  one  fifth  of  the  added  food  will 
be  furnished  as  work,  the  rest  being  dissipated 
as  heat.  It  is  in  harmony  with  this  principle 

1  Heubner  &  Rubner:  Leitschr.  f.  Biologic,  vol.  36,  p.  1,  and  vol.  38, 
p.  315. 


22 


LECTURES  ON  DIETETICS 


that  soldiers  receive  much  higher  food  rations 
in  war-time  than  in  peace.  Thus  the  Caloric 
value  of  the  Soldiers*  food  ration  is  as  follows: 


In  peace 

In  war 

Great  Britain  

2,946 

3,987 

Germany  

2,592 

3,613 

France  

2,310 

.4,213 
3,079 

3,413 

The  TJ.  S.  garrison  ration  calls  for  4.600  Calor- 
ies daily,  and  the  modified  garrison  ration  for 
4,800.  The  actual  food  intake  in  the  training 
camps,  as  gathered  from  the  data  of  87  messes, 
shows  a  consumption  of  4,000  Calories  a  day 
thus  distributed  between  the  groups  of  nutrients : 
proteins,  14%;  fats,  30%;  carbohydrates,  56%. 
(See  editorial:  "The  Food  of  the  Army."  Journal 
American  Medical  Association,  June  15th  1918). 

According  to  Murlin1  the  British  army  allows 
one  pound  of  meat  per  man  a  day,  the  French 
army  %  pound,  while  the  U.  S.  army  furnishes 
pounds. 


1  J.  R.  Murlin:  Some  Problems  of  Nutrition  in  the  Army  Science, 
1918,  vol.  47,  p.  495. 


PRINCIPLES  OF  DIET  AND  NUTRITION   23 


COMPOSITION  OF  THE  MOST  COMMON  FOOD  SUBSTANCES 
I.  DAIRY  PRODUCTS 


Protein, 
per  cent 

Fat, 
per  cent 

Carbo- 
hydrate, 
per  cent 

Calories, 
per  100 

Cow's  milk  

4.0  to  4.  3 

3.0  to  3.8 

3.7 

64 

Cream  

3  61 

26  75 

3  52 

276  01 

Butter  

0  5 

90  0 

0  5 

837 

Whey  

0.5 

0.3 

3.6 

7.30 

Buttermilk  

3.0 

1.3 

3.0 

37.5 

Kumyss     (of     cow's 
milk)  

3.35 

2.07 

0.7  lactic 
acid 
1.9  alcohol 

32.99 

Cheese  (cream)  

25.0 

30.0 

0.8  carbonic 
acid 
3.0 

394 

Cheese  

33.0 

9.0 

5.0 

240 

ERR.  . 

12.5 

12.0 

0.5 

165 

LECTURES  ON  DIETETICS 

II.  MEATS  AND  GAME 


Protein, 
per  cent 

Fat, 
per  cent 

Carbo- 
hydrate, 
per  cent 

Calories, 
per  100 

Beef  (fat)  

17.19 

26.38 

315.81 

Beef  (lean)  

20.78 

1.50 

99.15 

Veal  (fat)  

18.88 

7.41 

0.07 

146.61 

Veal  (lean)  

19.84 

0.82 

86.97 

Mutton  (very  fat)  .... 
Mutton  (leaner)  

14.80 
17.11 

36.39 

5.77 

0.05 

399.31 
123  81 

Pork  (fat)  

14.54 

37.34 

406  88 

Pork  (lean)  

20.25 

6.81 

146.36 

Ham  (Westphalian)  .  . 
Sweetbread  

28.97 
22.0 

36.48 
0.4 

1.50 

453.69 
93.92 

Pulverized  meat 

64.5 

5.24 

2.28 

322  53 

Poultry  

22.0 

1.0 

100 

Spring  chicken     

18.49 

9.34 

1.20 

167  59 

Duck  (wild)  

22.65 

3.11 

2.33 

131.36 

Squab  

22.14 

1.00 

0.76 

100.07 

Game  

23.0 

1.0 

103.60 

Hare  

23.84 

1.13 

0.19 

107.08 

Venison  

19.77 

1.92 

1.42 

105.44 

III.  FISH 


Protein, 
per  cent 

Fat, 
per  cent 

Carbo- 
hydrate, 
per  cent 

Calories, 
per  100 

Pike  

18.5 

0.5 

0.75 

83.57 

Carp  

20.61 

1.09 

94.64 

Shellfish      

17.09 

9.34 

156  93 

Salmon         

15.01 

6.42 

2.85 

132  .  93 

Sardellen  

22.80 

2.21 

0.45 

113.83 

Oysters  

4.95 

0.37 

24 

Salt  herring  

19.5 

17.0 

0.5 

Caviar        

28.04 

16.26 

7.82 

PRINCIPLES  OF  DIET  AND  NUTRITION   25 

IV.  CEREALS  AND  VEGETABLES 


Protein, 
per  cent 

Fat, 
per  cent 

Carbo- 
hydrate, 
per  cent 

Calories, 
per  100 

Sago.  .  . 

0.5 

traces 

86.5 

356.70 

Wheat  flour     

8.5 

1.25 

73.0 

345.78 

Rye  flour  

10.0 

2.0 

69.0 

342.50 

Wheaten  bread 

6.0 

0.75 

52.0 

245 

Rye  bread     

4.5 

1.0 

46.0 

216 

Roll  

6.82 

0.77 

43.72 

213.87 

Zwieback  

9.5 

1.0 

75.0 

356 

Cauliflower     

2.0  to  5.0 

0.4 

4.0 

35 

Carrots  

1.04 

0.21 

6.74 

33.85 

Asparagus  

2.0 

0.3 

2.5 

21 

Rice     .            

5.5 

1.5 

75.0 

348  .  10 

Beans  

19.5 

2.0 

52.0 

311.75 

Peas  

19.5 

2.0 

54.0 

319.95 

Potatoes  

1.5 

20.0 

88 

Oatmeal  

12.5 

5.26 

66.77 

338  .  80 

Barley  meal  

8.31 

0.81 

75.19 

323 

Spinach  

3.49 

0.58 

4.44 

38 

Pickles  

1.02 

0.09 

0.95 

26 


LECTURES  ON  DIETETICS 


V.  SOUPS  AND  BEVERAGES 


Protein, 
percent 

Fat, 
per  cent 

Carbo- 
hydrate, 
per  cent 

Calories, 
per  100 

Milk  soup  with  wheat 
flour  

6.0 

3.25 

15  0 

112 

Meat  broth  (ordinary) 
Meat  juice  (pressed). 
Beef  tea  

0.4 
6.0to7.0 
0.5 

0.6 
0.5 
0.5 

Leube's  meat  solu- 
tion   

9.0  to  11.0 
albumin 
+1.79  to 

Barley  soup  

6.5  pep- 
tone 
1.5 

1.0 

11.0 

60.96 

Malt  extract  

8.0  to  10.0 

55.0 

258.30 

Rice  pap  with  milk  .  .  . 
Coffee  

8.8 
3.12 

3.5 

5.18 

28.6 

182.61 

Tea  

12.88 

Beer  

0.5 

5.25 

0.3 

Porter  

0.7 

6.0 

0.3 

60 

VI.  FRUITS 


Free  acid, 
per  cent 

Protein, 
per  cent 

Fat, 
per  cent 

Carbo- 
hydrate, 
per  cent 

Apples 

0.82 

0.86 

7.22 

Pears  

0.20 

0.36 

3.54 

Plums  

1.50 

0.40 

4.68 

Peaches  

0.92 

0.65 

7.17 

Grapes  

0.79 

0.59 

1.96 

Strawberries  

0.93 

0.54 

0.45 

1.01 

Chestnuts  

5.48 

1.37 

38.34 

Sugar  cane  

3.40 

Honey  

1.20 

5.28 

PRINCIPLES  OF  DIET  AND  NUTRITION   27 

VII.  FOOD  VALUES  IN  HOUSEHOLD  MEASURES.    (CALORIES) 


Foods  as  eaten 

Actual 
amount 

Household  measure 

Calories 

Dairy,  milk  

8  oz. 
8  oz. 

15  gms. 

20  gms. 
10  gms. 

15  gms. 

50  gms. 
15  gms. 

5  oz. 
50  gms. 

50  gins. 
16  gms. 

25  gms. 
40  gms. 
7  gms. 
40  gms. 
5  gms. 
30  gms. 
8  oz. 
8  oz. 
25  gms. 
95  gms. 
35  gms. 
30  gms. 
35  gms. 
35  gms. 
25  gms. 
35  gms. 
120  gms. 
45  gms. 
100  gms. 
130  gms. 
100  gms. 
100  gms. 
50  gms. 
40  gms. 
40  gms. 
20  gms. 
45  gms. 
12  gms. 

1  oz. 

1  OS. 

8  gms. 
10  gms. 
4  gms. 
10  gms. 
10  gms. 

A  glass  

160 
80 
30 
60 
70 
35 
80 
65 
45 
70 
75 
55 

20 
35 
105 
70 
150 
200 
8 

70 
115 
30 
35 
20 
110 
75 
160 
25 
90 
40 
35 
35 
40 
20 
20 
75 
70 
100 
70 
40 
350 
160 
55 
135 
75 
80 
85 

85 
15-50 
33 
33 
37 
65 
50 

Skimmed  milk  and  buttermilk. 
r<_«  ™  /  thin,  20  per  cent    \ 
Cream  (  thick.  40  per  cent  /  •  • 

Condensed  {SSSLd}- 
Butter  

A  glass  

A  tablespoon   

A  heaping  teaspoon  
A  heaping  teaspoon  

f  Cream         1 
Cheese  {  Skim-milk  [  
1  American   j 
Eggs,  whole  

One-inch  cube  

One-inch  cube  

One  

Eggs,  yolk  

One  

Meat  and  fish  (cooked): 

Woi,  /  lean  (cod,  flounder)  \ 
™h  1  fat  (shad,  salmon)     /  •  ' 
f  lean 
Meat  <  medium  fat  r  

A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  . 

5  X  3  X  >i  inch  

I  fat 
Oysters,  medium  size  (raw)  .... 
Cereals  and  vegetables  (cooked): 
Bread,  white  or  graham  

One  

Oneslice,  4  X4  X  H-.. 
One  

Vienna  roll  

One  

Cereals,  cooked,  moist  

A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  .  . 
One     

Cereals,  eaten  dry  

Shredded  wheat  

Gruels  (cereal)  

A  soup  plate  

Thickened  or  cream  soups  
Macaroni  

A  soup  plate  

A  heaping  tablespoon  .  .  . 

Potato,  boiled  or  baked  

Potato,  mashed  

A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon  .  .  . 

Rice,  boiled  ,  

Corn,  canned  

Peas,  fresh  

Lima  beans,  canned  

Fruits,  apple,  pear  

Apple  sauce  

A  heaping  tablespoon  .  .  . 

Banana  

Orange  

One  medium  size  

Strawberries  

A  medium  saucerful.  .  .  . 
A  medium  saucerful  .... 
A  heaping  tablespoon.  .  . 
A  heaping  tablespoon  .  .  . 
A  heaping  tablespoon.  .  . 
A  slice  2  X4  X  J4  inch. 
A  heaping  tablespoon  .  .  . 

Fruit  j  efiy  ,  sweetened  

Desserts,  custard  

Sponge  cake  

Pudding  (rice,  tapioca,  bread). 
Alcohol  

Whiskey,  brandy,  etc.  (50  per 
cent)  

Wines  (8-25  per  cent)  

A  small  wineglass  
A  heaping  teaspoon  
A  heaping  teaspoon  

Honey  

Olive  oil  

A  heaping  teaspoon  
A  heaping  teaspoon  

Cocoa  powder  

Arranged  after  Franklin  H.  White  of  Boston,  Mass. 


28  LECTURES  ON  DIETETICS 

Food  tables  have  been  prepared  indicating 
now  much  albumin,  carbohydrate,  and  fat  each 
food  article  contains,  and  by  using  these  you 
can  know  how  much  of  each  of  these  substances 
is  contained  in  bread,  meat,  or  vegetables  and 
you  can  make  out  how  many  heat  units  they 
will  develop.  On  the  preceding  pages  will  be 
found  several  tables  of  the  composition  of  the 
most  common  food  substances,  showing  also 
the  heat  units  they  contain.  (Tables  I- VII.) 

Usually  we  find  that  all  food  articles  contain 
two  or  three  of  these  substances,  proteins  and 
carbohydrates,  or  carbohydrates,  fats,  and  a 
trace  of  protein,  etc.  Animal  foods  contain 
principally  protein  and  fat;  and  the  vegetable 
foods  contain  carbohydrates  and  protein  and 
very  little  fat. 

On  the  whole,  in  the  average  diet,  people 
take  the  greater  amount  of  protein  from  animal 
food,  and  the  greatest  amount  of  carbohydrate 
from  the  vegetable  kingdom.  The  physiolo- 
gists advocate  taking  a  larger  amount  of  protein 
from  plants.  Two-thirds  of  the  protein  ingested 
should  be  from  vegetable  food,  and  only  one- 
third  from  animal  food.  In  the  majority  of 
instances  in  this  country  and  England  this  point 


PRINCIPLES  OF  DIET  AND  NUTRITION   29 

is  not  heeded,  and  people  take  protein  princi- 
pally from  animal  food, — eating  meat  three 
times  a  day.  This  is  easy  for  the  organism,  as 
it  is  not  bulky  and  can  be  eaten  quickly.  It  is 
the  most  expensive  article  of  food,  but  it  is  not 
always  the  best,  and  it  is  apt  to  bring  on  condi- 
tions which  are  not  good, — gouty  tendencies, 
and  disturbances  of  the  liver,  etc.  For  healthy 
living,  it  is  rather  better  to  choose  the  proteins 
to  a  great  degree  from  the  vegetable  kingdom. 
Next  lecture  our  subject  will  be  the  digesti- 
bility of  food,  and  we  will  see  how  to  estimate  the 
digestibility  of  what  is  eaten,  and  we  will  take 
up  the  subject  of  diet  in  health  and  diet  in 
disease. 


LECTURE  II 

THE  DIGESTIBILITY  OF  FOODS,  AND  THE  DIET  IN 
HEALTH  AND  ACUTE  DISEASES 

We  will  start  to-day  with  the  subject  of  the 
digestibility  of  food.  How  can  we  estimate 
which  food  is  easy  to  digest  and  which  is  not? 
When  Beaumont  had  a  patient  with  a  gastric 
fistula,  he  thought  he  would  find  out  about  that. 
For  at  that  time  it  was  considered  that  the 
stomach  was  the  main  organ  of  digestion,  and  he 
thought  that  if  food  was  found  in  the  stomach 
after  a  long  time  it  would  indicate  that  the  diges- 
tion of  that  food  was  not  easy.  On  the  other 
hand,  he  thought  that  if  a  certain  article  of  food 
leaves  the  stomach  in  a  short  time,  it  would 
indicate  that  it  was  easy  to  digest.  So,  having 
this  patient  with  a  gastric  fistula,  he  thought 
he  would  watch  when  the  stomach  emptied 
after  certain  articles  of  food,  and  he  made  out 
a  scale  of  the  digestibility  of  food  accordingly. 

In  recent  years,  now  that  we  are  using  the 
stomach  tube  so  frequently,  physicians  do  not 

80 


THE  DIGESTIBILITY  OF  FOODS  31 

need  to  have  a  patient  with  a  fistula  in  order  to 
watch  the  time  when  the  food  leaves  the  stomach, 
but  can  empty  or  wash  out  a  stomach  after  a 
meal  and  examine  its  contents.  This  has  been 
practiced  by  Leube,  and  later  by  Penzoldt. 
They  took  healthy  individuals,  medical  students 
who  were  willing  to  take  test  meals  and  then 
have  lavage  practiced,  or  a  tube  introduced, 
to  find  out  whether  or  not  certain  foods  had  left 
the  stomach.  Penzoldt  has  arranged  a  table 
showing  what  time  certain  articles  of  food  require 
for  digestion  in  the  stomach. 

Most  physicians  think  that  the  shorter  the 
time  required  for  digestion  in  the  stomach,  the 
easier  the  digestion  of  that  article.  On  further 
reflection,  however,  one  can  see  that  this  is  not 
a  good  gauge  to  go  by.  In  reality,  the  main 
place  for  digestion  is  not  the  stomach,  but  the 
small  intestine.  The  stomach  prepares  the 
food,  but  the  actual  digestion,  for  the  greater 
part,  takes  place  in  the  small  intestine,  and  there 
the  absorption  occurs.  Many  substances  leave 
the  stomach  without  any  change  at  all — the  fatty 
'substances,  for  instance.  According  to  my 
experience,  the  main  place  for  the  digestion  of 
meat  is  not  the  stomach  but  the  intestine.  The 


32  LECTURES  ON  DIETETICS 

muscle  fibers  become  swollen  in  the  stomach, 
but  they  don't  disappear.  Connective  tissue  is 
one  of  the  substances  that  are  absorbed  in  the 
stomach.  Then,  we  have  some  of  the  starchy 
substances  which  have  already  changed  into 
sugar,  which  likewise  are  absorbed  here.  But 
everything  else  leaves  the  stomach,  and  enters 
the  small  intestine  for  further  changes  there. 
So  the  time  the  food  remains  in  the  stomach  is 
not  enough  of  a  guide  as  to  its  digestibility. 

Another  plan  of  judging  of  the  digestibility 
of  food  is  to  see  whether  it  leaves  a  residue  in  the 
digestive  apparatus  or  not — that  is,  whether  it 
entirely  disappears.  If  a  certain  article  of  food 
leaves  a  great  deal  of  residue,  and  part  of  it 
passes  through  the  entire  digestive  tract,  it 
cannot  be  considered  very  digestible;  while  food 
that  leaves  no  residue  must  be  considered  easy 
of  digestion.  So  another  scale  has  been  made 
out  according  to  that. 

As  a  general  rule,  we  can  say  that  all  animal 
food  leaves  less  residue  and  is,  in  a  way,  more 
digestible  than  all  vegetable  food.  All  vege- 
table food  leaves  more  residue,  no  matter  what 
it  is:  seeds,  nuts,  etc.,  those  vegetable  foods 
rich  in  protein,  that  come  in  prepared  forms — 


THE  DIGESTIBILITY  OF  FOODS  33 

flour,  meal, — leave  less  residue  than  those 
materials  which  represent  other  vegetables,  such 
as  roots — like  potatoes — or  leaves  and  stems 
that  contain  a  great  deal  of  cellulose  matter; 
also  most  foods  that  grow  on  trees  contain  a 
great  deal  of  cellulose,  which  leaves  a  large 
amount  of  residue. 

Of  animal  foods,  it  has  been  found  that  those 
meats  that  contain  less  fat  are  easier  of  diges- 
tion than  those  that  contain  a  considerable 
amount  of  fat.  For  instance,  pork  takes  a 
longer  time  in  the  stomach  and  also  leaves  more 
residue  than  beef;  so  you  have  another  point  on 
which  to  judge  of  the  digestibility. 

Another  way  of  estimating  the  digestibility 
of  food  is  by  its  physical  character.  All  food 
before  being  absorbed  must  be  changed  into 
a  liquid  form.  The  organism  cannot  take  up 
any  substance  unless  it  is  in  a  gaseous  or  liquid 
form,  or  emulsified.  Solid  substances  cannot 
penetrate  the  tissues.  If  we  have  to  deal  with 
foods  that  are  liquid  from  the  start,  we  can  judge 
that  their  absorption  will  be  much  easier  than 
that  of  solid  substances  which  have  to  be  changed 
into  the  liquid  form.  So  you  can  make  out  a  scale 
of  the  digestibility  of  foods  according  to  their 


34  LECTURES  ON  DIETETICS 

physical  characteristics — whether  or  not  they 
are  easily  changed  into  liquids.  In  this  way  we 
will  have  in  that  group  which  is  more  easily 
digested,  or  Group  I,  liquid  food;  milk,  broths 
and  gruels;  eggs  beaten  up  in  milk  — emulsified— 
are  easy  to  digest;  also  beef  juice — the  juice 
pressed  out  from  the  meat.  Group  II;  liquid 
at  body  temperature:  fruit  jellies  and  meat 
jellies,  calves-foot  jelly,  ice  cream  that  melts  at 
body  temperature,  butter,  all  these  are  easily 
digested. 

Group  III.  Foods  that  are  easily  broken  up 
into  fine  particles  beforehand,  such  as  mashed 
potato;  or  where  some  mechanical  movement  is 
necessary  to  divide  the  food  into  fine  particles, 
already  prepared,  mashed,  etc.,  powdered  meat, 
all  mashed  vegetables,  purees;  soft  boiled  and 
poached  eggs  belong  to  the  same  group;  bread 
and  crackers  dried  and  pulverized,  toast  and 
bread  cut  up  or  ground  up  nicely  and  put  into 
some  liquid. 

Group  IV.  Foods  that  are  not  easily  broken 
up,  but  still  change  easily  and  do  not  present  too 
much  resistance  to  mechanical  division,  such 
as  bread,  boiled  potatoes  and  vegetables  not 
made  into  purees;  foods  such  as  sweetbreads, 


THE  DIGESTIBILITY  OF  FOODS  35 

calves'  brains,  and  fish  are  a  little  lighter  than 
other  kinds  of  meat,  like  chicken  and  chops, 
and  are  easier  to  mash  up  and  chew. 

Group  V.  Where  the  division  is  a  little  harder. 
Here  we  have  the  meats  that  have  stronger  fibers. 
Boiled  lobster  does  not  divide  up  so  quickly  as 
tender  meat;  fruits,  where  a  great  deal  of  chew- 
ing is  required  to  break  them  up. 

Group  VI.  This'/is  the  hardest  group — salads, 
raw  vegetables,  cheese,  and  foods  that  con- 
tain a  great  deal  of  sulphur — such  as  cabbage,  etc. 

According  to  these  lines  you  can  see  whether 
a  food  is  easily  digested  or  not,  and  if  you  act 
according  to  this  scale  you  will  see  that  it  corre- 
sponds with  the  other  scales  mentioned  before. 

DIET  IN  HEALTH 

Now,  speaking  about  diet  in  health,  is  it  good 
for  healthy  persons  to  abstain  from  food  sub- 
stances that  are  not  easily  digestible?  There 
are  a  great  many  persons  who  think  that  if  they 
avoid  all  kinds  of  hard  foods,  and  live  on  the 
finest  articles,  milk,  eggs,  soups,  etc.,  they  are 
better  off  and  do  not  get  sick,  but  in  my  opinion 
that  is  not  the  right  way  to  live.  It  is  rather 
advisable  to  harden  the  system.  If  you  live 
on  only  light  diet  for  some  time,  and  then  on 


36  LECTURES  ON  DIETETICS 

some  occasion  have  to  take  something  else,  you 
are  liable  to  get  sick;  the  digestive  tract  is  not 
accustomed  to  it.  In  normal  conditions,  it  is 
best  to  have  a  liberal  diet  and  not  to  select  foods 
that  are  easily  digestible.  You  should  rather 
mix  your  diet;  take  some  substances  that  are 
more  difficult  to  digest,  and  accustom  yourself 
to  a  variety  of  food.  If  a  man  has  accustomed 
himself  never  to  take  salads  and  once  in  a  while 
has  to  take  some  raw  foods,  he  is  likely  to  get 
sick  and  need  some  medicine.  People  in  health 
should  have  a  liberal  diet,  and  should  include 
some  substances  that  are  not  so  easily  digested. 
Should  people  eat  fast  or  slowly?  Here 
again  the  golden  rule  is  in  the  middle.  The 
food  should  not  be  eaten  too  fast,  nor  yet  too 
slowly.  One  reason  for  that  is  that  if  you  eat 
too  slowly  and  are  used  to  it,  and  then  some 
day  have  to  hurry  and  take  a  meal  a  little  more 
quickly,  you  will  get  sick.  Again,  if  your  appe- 
tite is  not  so  good,  and  you  are  used  to  eating 
slowly,  you  will  get  tired  of  your  food  and  stop 
in  the  middle  of  a  meal.  I  have  found  that 
severe  conditions  develop  sometimes  from  eating 
too  slowly,  especially  in  persons  who  are  not  so 
well.  They  are  imbued  with  the  notion  of  eating 


THE  DIGESTIBILITY  OF  FOODS  37 

slowly,  and  counting  so  many  times  before  swal- 
lowing; they  grow  tired  of  eating,  and  their 
appetites  are  not  good,  and  instead  of  eating  a 
good  dishful  they  eat  only  a  few  mouthfuls;  so 
they  are  not  well  nourished,  and  become  nervous, 
etc. — all  due  to  that  habit  of  slow  eating. 

Fast  eating,  also,  is  not  good.  Some  very 
disagreeable  conditions  develop  from  swallow- 
ing the  food  too  quickly,  not  chewing  it  up  and 
masticating  it  properly.  It  may  go  on  for  a 
while  without  apparent  harm,  but  after  a  while 
some  obnoxious  conditions  develop,  perhaps 
some  catarrhal  condition  or  a  functional  dis- 
turbance of  the  digestive  apparatus.  So  take 
time  for  your  meals,  but  do  not  overdo  it.  Live 
sensibly  and  have  a  good  meal,  and  have  a  little 
conversation  with  your  meals,  and  have  to  wait 
for  one  dish  and  then  another.  Once  in  the 
country  I  asked  a  lady  to  go  out  for  a  ride  with 
me.  She  said:  "Before  I  go,  I  would  like  to 
have  a  glassful  of  milk."  I  said:  "Certainly." 
But  instead  of  taking  a  glassful  of  milk  and 
drinking  it,  she  sipped  and  sipped,  and  took  a 
half  hour  to  drink  the  milk.  She  suffered  from 
headaches,  and  then  she  became  my  patient. 
She  consulted  me,  and  I  knew  right  away  what 


38  LECTURES  ON  DIETETICS 

was  wrong.  I  tried  to  convert  her  to  another 
way  of  living,  and  succeeded,  and  she  is  much 
better  off  now.  That  was  an  instance  of  the 
evil  of  slow  eating,  and  how  I  discovered  the 
cause. 

How  many  meals  should  a  normal  person  have? 
Should  we  eat  twice  a  day,  three  times  a  day, 
or  five  times  a  day?  There  are  people  who  do  all 
of  these  ways  and  enjoy  perfect  health.  This 
question  cannot  be  answered  off-hand.  I  think 
the  customs  of  the  country  in  which  one  lives 
are  the  best  guides  to  follow.  Here  in  America, 
people  eat  three  times  a  day,  as  a  general  rule— 
a  good  breakfast,  a  good  supper — morning  and 
night.  At  noon  time,  they  are  away  from  home, 
and  have  only  a  light  luncheon.  Two  good 
sized  meals  and  one  small  one  between.  The 
reason  for  that  is  that  they  are  not  at  their 
homes,  are  far  away,  and  have  to  be  satisfied 
with  a  little  something  at  the  business  hour— 
so  that  is  the  best  for  them.  They  have  their 
heavy  meals  at  home,  prepared  to  suit  them, 
and  in  the  middle  of  the  day  they  take  something 
to  meet  the  requirements.  People  in  the  coun- 
try, or  who  are  at  home  and  do  not  have  to  leave 
the  house  for  their  meals,  usually  have  a  smaller 


THE  DIGESTIBILITY  OF  FOODS  89 

meal  in  the  morning,  take  a  good  luncheon  or 
dinner  in  the  middle  of  the  day,  and  have  another 
small  meal  in  the  evening.  Usually  the  morning 
meal  is  the  smallest,  the  one  in  the  middle  of  the 
day  is  the  largest,  and  the  second  in  size  is  the 
supper — so  for  them,  that  is  all  right.  In 
Germany,  they  are  used  to  taking  a  very  small 
breakfast — only  coffee  and  a  roll.  They  eat 
no  eggs  then,  but  they  have  another  breakfast  at 
ten  o'clock  or  half-past  ten.  Prof.  Virchow  used 
to  lecture  at  11  o'clock,  and  he  came  into  his 
lecture  room  about  half  after  ten  and  had  a 
sandwich  and  a  glass  of  beer.  That  was  his 
regular  custom.  That  is  their  way.  They 
take  something  in  the  morning,  and  then 
something  additional  a  little  later;  then  have 
luncheon,  and  again  something  in  the  afternoon 
at  half -past  three — coffee,  with  a  little  bread. 
They  have  more  time  there  and  are  more  socia- 
ble. They  go  to  the  caf£s  and  restaurants,  and 
spend  some  time  there,  and  have  a  little  chat, 
and  then  go  on  their  way.  Whether  you  like  it 
or  not,  that  is  an  easy  way.  Then  they  take 
their  supper,  and  go  out  again,  and  later  in  the 
evening  they  go  to  a  beer  garden,  and  take  a 
bite  again.  So  they  eat  perhaps  six  times  a  day. 


40  LECTURES  ON  DIETETICS 

That  is  not  obligatory,  but  it  is  customary,  and 
it  is  all  right.  It  has  a  tendency  to  fatten  them 
up.  On  this  account  you  perhaps  find  more  fat 
people  in  Bavaria,  and  Germany,  than  here. 
That  used  to  be  the  way  when  I  lived  there,  and 
it  is  an  easy  way  of  li ving.  Frequent  eating  and 
doing  less  work  tends  to  corpulency,  and  that  is 
what  we  find.  In  this  country  corpulence  is 
not  a  frequent  disease.  Not  one  of  you  here 
has  that  characteristic.  The  different  mode  of 
living  and  eating  is  the  reason  for  it.  In  Europe, 
you  might  find  half  a  dozen  or  more  fat  persons 
among  such  a  number. 

The  best  way  is  not  to  change  the  custom  of 
the  country,  but  to  do  what  others  do.  The 
majority  rules.  Don't  try  to  do  better  than 
the  others.  Go  along  with  them  and  you  will  be 
all  right.  That  is  the  best  rule. 

DIET  IN  DISEASE 

We  may  for  our  purpose  divide  all  diseases 
into  two  classes,  for  in  these  groups  the  diet  is 
quite  different.  One,  in  which  the  disease  is  of 
an  acute  character  and  lasts  only  a  short  while. 
In  the  second  group,  we  have  to  deal  with 


THE  DIGESTIBILITY  OF  FOODS  41 

chronic  conditions,  or  diseases  lasting  over  long 
periods. 

We  will  start  to-day  with  the  diseases  of  short 
duration.  Here  the  main  point  is  to  see  that 
the  digestive  tract  is  not  burdened  with  much 
work.  The  principle  of  rest  plays  the  greatest 
part  in  any  disease,  especially  in  regard  to  diet. 
In  any  disease,  no  matter  what — of  the  stomach, 
liver,  kidneys,  lungs — the  organism  requires 
rest.  You  have,  for  instance,  a  patient  with 
pneumonia.  He  has  been  all  right,  right  along, 
but  now  he  is  attacked  with  pneumonia.  Here 
it  would  be  wrong  to  prescribe  plenty  of  nourish- 
ment, He  does  not  need  it,  and  you  would  only 
make  him  worse  if  you  force  him  to  take  food. 
Nature  has  provided  for  that,  and  gives  hints 
in  regard  to  the  method  of  procedure.  When  a 
man  is  taken  sick,  he  suddenly  loses  his  appetite 
and  has  an  aversion  for  food,  and  tells  you  to 
leave  him  alone.  That  is  what  nature  does, 
and  it  is  the  correct  way.  His  body  is  in  good 
nutrition,  and  no  harm  is  done  if  in  that  period 
of  sickness — which  usually  lasts  from  three  to 
six  or  seven  days — he  does  not  have  food.  His 
organism  has  enough  material  in  it  to  utilize  dur- 
ing that  period  of  emergency.  It  is  rather  best 


42  LECTURES  ON  DIETETICS 

to  act  on  the  principle  of  rest  and  not  to  burden 
the  system  with  food  that  is  not  essential.  Keep 
such  a  patient  quiet  in  bed,  with  cold  ablutions 
of  the  body  or  something  of  that  sort;  and  left 
alone,  the  organism  has  a  good  chance  to  fight 
the  disease.  This  principle  prevails  everywhere 
in  all  diseases.  The  patient  may  lose  say 
eight  or  ten  pounds  during  the  disease,  but  as 
soon  as  the  period  of  fever  or  the  acute  stage  is 
over,  the  appetite  will  come  back,  the  patient  is 
hungry — even  more  so  than  formerly — he  eats 
more  and  quickly  replaces  what  was  lost. 

But  while  it  is  not  essential  to  introduce  much 
food  into  the  organism  during  the  period  of 
acute  illness,  it  is  essential  to  look  out  for  the 
amount  of  fluids  in  the  system.  You  must  not 
say :  ' '  Give  the  patient  nothing' ' — that  is  wrong ; 
but  you  must  see  that  he  gets  enough  water. 
That  is  a  very  important  point.  The  reason 
for  that  is  that  a  man  in  good  condition — a 
normal  individual,  a  healthy  man — if  deprived 
of  food  but  supplied  with  water,  can  live  for 
twenty  or  thirty  days  upon  the  material  supplied 
from  the  body.  There  are  professional  starva- 
tion men  who  practice  that,  and  have  been  able 
to  live  thirty  or  forty  days  on  water  alone — 


THE  DIGESTIBILITY  OF  FOODS  43 

using  their  bodi  es  to  live  upon .  At  the  end  of  that 
time,  they  resume  eating  and  are  again  all  right. 
If  in  addition  you  take  away  water,  however, 
the  period  of  life  is  shortened.  One  can  live 
only  three  or  seven  days  at  the  utmost  without 
water.  Why  cannot  a  man  live  a  little  longer? 
He  has  enough  in  his  body  to  live  upon;  there  is 
enough  flesh  and  fat  in  the  body  to  live  upon,  and 
yet  he  dies.  The  reason  for  that  is  that  there 
is  a  shortage  of  water,  of  fluids,  in  the  system. 
We  use  up  a  great  deal  of  fluid,  by  respiration, 
perspiration,  by  excretion  through  the  kidneys, 
etc.  We  lose  at  least  two  or  three  quarts  of 
fluids  daily  in  this  way.  If  it  is  not  there,  the 
organism  takes  it  from  the  fluids  in  the  system, 
the  tissues  dry  up,  the  blood  thickens,  and  the 
man  dies.  In  two  days  we  lose  six  quarts,  that 
is  twelve  pounds  from  the  fluids.  Then  what 
happens  ?  There  is  plenty  of  nutritive  substance 
in  the  organism,  but  the  blood  has  become  thick- 
ened, the  capillaries  cannot  work,  the  substances 
which  are  in  the  system  cannot  replace  those 
which  are  needed,  the  traffic  is  cut  off,  the  rivers 
are  dried  up,  the  vessels  cannot  go,  and  the  man 
dies.  He  dies  not  so  much  from  lack  of  food 
material  as  from  lack  of  fluids. 


44  LECTURES  ON  DIETETICS 

In  the  acute  diseases,  the  loss  of  fluids  is 
increased.  During  fever  a  patient,  instead  of 
losing  three  quarts  of  fluid  a  day  loses  four  or 
five.  If  you  do  not  see  that  the  patient  drinks, 
or  that  something  is  given  him  to  replace  the 
loss  very  quickly,  there  will  be  something 
wrong.  So,  while  it  is  not  necessary  to  intro- 
duce much  food  into  the  system  during  an 
acute  illness,  the  necessity  of  introducing  fluids 
is  increased. 

There  is  another  reason  why  fluids  are  essential 
during  the  acute  stage  of  disease.  In  most 
instances  we  have  to  deal  with  infections,  and 
there  are  toxic  substances  developed  through 
the  system  by  bacterial  action.  These  have 
to  be  removed  from  the  system,  and  we  can  do 
this  quickly  if  we  flush  the  system.  Give  them 
more  water  than  they  need.  They  have  to  pass 
more  water,  and  the  water  must  reach  the  circu- 
lation first  before  it  is  carried  off,  and  that  washes 
out  the  system. 

I  will  give  you  one  instance  of  this,  for  I 
think  that  those  things  which  really  occur  impress 
us  more  than  anything  else,  so  I  will  tell  you 
of  something  that  happened  to  me.  When  I 
was  a  little  boy,  I  was  in  Russia,  visiting  some 


THE  DIGESTIBILITY  OF  FOODS  45 

relatives,  and  cholera  developed  there.  They 
were  anxious  to  send  me  home,  as  was  quite 
natural,  and  the  carriage  was  waiting  for  me 
downstairs,  so  I  put  on  my  overcoat;  but  while 
I  was  getting  ready  to  go  down,  I  collapsed  and 
was  attacked  with  the  cholera,  and  became  un- 
conscious, vomited,  etc.  I  had  the  real  Asiatic 
cholera,  so  I  was  put  to  bed.  I  could  not  talk, 
could  not  do  anything.  There  were  several 
physicians  in  attendance,  and  they  thought  I 
was  going  to  die.  They  did  not  give  me  anything ; 
at  first  I  was  kept  without  anything,  but  when 
I  returned  to  consciousness  I  was  very  thirsty, 
as  was  quite  natural,  but  the  two  physicians 
thought  differently.  They  called  in  a  third 
physician,  and  he  said  "Give  him  water;  if  he 
is  thirsty,  let  him  drink."  So  they  put  a  big 
pitcher  of  water  next  to  my  bed,  and  I  emptied 
it  once,  a  second,  a  third  time.  I  was  drinking 
all  the  while.  After  a  period  of  a  week  or  ten 
days,  during  which  I  was  almost  dead,  I  began 
to  recuperate,  and  you  see  I  am  still  living.  I 
think  that  water  saved  my  life  at  that  time.  I 
am  quite  sure  that  if  it  had  not  been  given  to 
me  I  would  not  have  had  a  chance  of  recovery. 
I  want  to  impress  upon  you  the  necessity  of 


46  LECTURES  ON  DIETETICS 

giving  liquids.  If  a  patient  is  thirsty,  let  him 
drink.  But  supposing  he  is  not  thirsty,  is 
apathetic,  does  not  want  anything,  lets  himself 
go.  Is  it  necessary  to  remind  him?  I  think  it 
is.  You  must  look  out,  even  then.  The  fluids 
should  be  given;  he  should  be  encouraged  to 
drink;  give  lemonade,  Apollinaris  water,  barley 
water,  etc.,  make  him  drink.  If  you  cannot 
accomplish  that,  introduce  the  water  into  his 
system  in  some  other  way;  through  the  bowels 
is  a  very  good  way.  Give  him  saline  injections. 
If  he  does  not  keep  that  and  is  very  weak,  and  does 
not  drink,  and  there  is  need  of  fluid,  you  can 
give  injections  subcutaneously,  under  the  skin, 
but  see  that  there  is  enough  fluid  in  the  system, 
especially  in  such  conditions  as  diarrhea,  vomit- 
ing, etc. 

The  principle  of  introducing  liquids  into 
the  system  to  cover  the  loss  from  perspiration, 
etc.,  is  of  the  greatest  importance.  While,  as 
I  have  said,  it  is  not  essential  to  look  out  for 
the  nourishment  of  patients  in  these  acute  ill- 
nesses, there  are  exceptions  to  this  rule.  For 
instance,  you  may  have  to  deal  with  an  elderly 
individual,  say  a  patient  of  seventy  or  seventy- 
five.  Usually  such  patients  are  not  so  very 


THE  DIGESTIBILITY  OF  FOODS  47 

well  nourished,  people  of  this  age  usually  grow 
thin,  and  cannot  stand  much  loss,  and  there 
we  cannot  neglect  to  pay  attention  to  the  food, 
even  in  that  short  period,  but  see  that  they  take 
food  that  is  easily  digested.  Give  them  milk, 
say  every  two  or  three  hours,  decoctions  of 
barley  water,  etc.  Long  ago  Hippocrates  under- 
stood this,  and  gave  his  patients  the  ptisan, 
which  is  a  decoction  of  barley  water  and  sugar. 
Sugar  is  a  good  nutritive  material.  He  treated 
febrile  cases  by  cutting  off  food  and  giving  them 
barley  water  and  honey. 

For  the  next  lecture  we  will  take  up  the  second 
group  of  diseases,  and  we  will  consider  first  the 
subject  of  diet  in  more  prolonged  acute  diseases, 
such  as  typhoid  fever,  etc.,  and  in  chronic 
diseases. 


LECTURE  III 

THE  DIET  IN  ACUTE  DISEASES  OF  PROLONGED 
DURATION  AND  IN  CHRONIC  DISEASES 

Proceeding  with  the  subject  of  diet,  we  will 
to-day  take  up  the  question  of  diet  in  typhoid 
fever,  which  is  one  of  the  acute  diseases  that 
often  lasts  for  a  long  period  of  time,  and  requires 
special  attention.  In  former  times,  up  to  about 
seventy-five  years  ago,  it  was  the  tendency  of 
the  medical  profession  to  withhold  nourishment 
from  patients  with  typhoid  fever  and  to  give 
them  as  little  as  possible,  and  that  little  only  in 
liquid  form.  The  teachings  of  Hippocrates 
prevailed  especially  with  regard  to  this  terrible 
disease,  and  these  patients  would  get  only  a 
little  weak  tea  or  barley  water;  even  milk  was 
kept  away  from  them  as  it  was  considered  a 
form  of  nourishment  which  might  disturb  them 
too  much.  So  the  starvation  plan  was  carried 
out  in  this  disease  also,  up  to  the  time  of  con- 
valescence. 

The  renowned  clinician,  Dr.  Graves,  of  Great 
Britain,  was  the  first  one  to  try  to  introduce 

48 


THE  DIET  IN  ACUTE  DISEASES  49 

some  reform  in  the  treatment  and  management 
of  typhoid  fever  in  regard  to  diet.  He  thought 
that  the  starvation  method  was  not  a  good  way 
to  treat  these  patients  and  that  perhaps  a  great 
many  of  them  died  from  lack  of  nutrition — not  so 
much  from  the  fever  as  from  the  lack  of  nourish- 
ment— the  body  being  unable  to  fight  the  disease. 
So  he  thought  he  would  give  these  patients 
light  nourishment,  and  he  gave  them  milk, 
which  is  a  liquid  food  that  is  easily  digested. 
He  was  the  first  one  to  make  use  of  milk  in  the 
dietary  of  typhoid  fever  in  a  considerable  degree 
— to  give  them  a  good  amount  of  milk.  That 
theory  was  combated  by  the  clinicians  of  that 
day;  many  thought  that  he  killed  his  patients, 
and  like  all  innovators  he  had  a  great  many 
enemies.  The  profession  was  not  ready  to 
accept  the  great  change  of  giving  milk  to  patients 
with  typhoid  fever.  Graves  fought  his  battle, 
however,  and  finally  carried  it  through.  In  the 
meantime,  many  physicians  more  and  more 
adopted  his  plan.  Dr.  Graves  was  so  proud  of 
this  reform  of  introducing  milk  into  the  diet  of 
typhoid  fever  that  in  his  will  he  left  directions 
that  his  tomb  should  be  inscribed:  "He  fed 
fevers." 


50  LECTURES  ON  DIETETICS 

That  was  the  first  article  of  food  that  was 
added  to  the  dietary  of  typhoid  fever  patients 
for  many  years;  they  were  kept  on  a  diet  con- 
sisting of  milk,  broths,  and  gruels.  Then  came 
another  current  from  Russia.  There  are  a  few 
clinicians  there  who  tried  giving  typhoid  fever 
patients  an  ordinary  diet,  solid  food — any- 
thing. I  do  not  remember  the  name  of  the 
man1  who  first  introduced  this  treatment,  but 
at  any  rate  some  of  the  physicians  took  up  the 
plan  of  treating  these  patients  with  the  ordinary 
food — bread,  meat,  and  vegetables — and  still 
they  reported  results  that  were  not  worse  than 
if  the  patients  were  treated  with  very  fine  food 
in  their  diet.  They  claimed  that  their  patients 
thrived,  felt  stronger  and  better,  and  got  over 
the  disease  just  as  well.  Now,  you  will  ask, 
what  shall  we  do? 

In  my  opinion,  we  should  not  give  the  patient 
the  ordinary  daily  food.  That  would  be  too 
radical  a  change.  But  their  experience  has 
shown  that  we  need  not  be  too  much  afraid  of 
introducing  a  little  more  food  into  the  dietary 
of  these  patients,  and  that  typhoid  fever  patients 
need  not  always  be  restricted  to  strictly  liquid 

1  His  name  is  Bushuyev. 


THE  DIET  IN  ACUTE  DISEASES  51 

food.  We  may  give  them  a  semi-solid  diet, 
and  perhaps  in  some  cases  may  give  a  little  solid 
food. 

Now  another  point  has  emanated  from  this 
country.  I  think  the  beginning  of  this  was  in 
Germany,  but  it  was  not  carried  out  to  the 
extent  to  which  it  has  been  followed  out  in  this 
country.  A  great  many  years  ago,  Prof.  Leyden, 
of  Berlin,  who  has  done  so  much  for  the  dietetic 
treatment  of  diseases,  was  of  the  opinion  that 
with  typhoid  patients,  or  any  patients  with 
fever  who  lose  so  much  flesh,  we  might  by  in- 
creasing the  nourishment,  be  able  to  check  the 
loss.  It  has  been  for  quite  a  while  a  subject  of 
controversy  as  to  whether  this  could  be  done.  In 
such  fevers,  the  expenses  of  the  body  are  in- 
creased and  the  intake  is  diminished,  and  it  was 
a  question  as  to  whether  the  digestive  system 
would  be  able  to  take  up  the  food,  which  would 
balance  or  outbalance  the  loss.  That  question 
had  not  been  decided  until  Dr.  Warren  Coleman 
of  this  city  took  it  up  and  carried  the  point 
so  far  as  to  prove  that  you  can  give  a  typhoid 
fever  patient  enough  nourishment  to  prevent 
him  from  losing  flesh.  Sometimes  you  can  even 
make  him  gain  during  the  febrile  period.  It  is, 


52  LECTURES  ON  DIETETICS 

therefore,  only  a  question  of  the  quantity  of 
nourishment  introduced,  whether  he  loses  or 
not.  Dr.  Coleman  of  Bellevue  Hospital  really 
did  a  great  deal  of  meritorious  work  in  this  line. 
Some  years  ago  I  tried  to  nourish  some  of  these 
patients  in  the  German  Hospital,  (now  Lenox 
Hill  Hospital),  giving  them  larger  amounts  of 
food.  We  gave  them  milk  and  added  raw  eggs- 
three  or  four  a  day,  beaten  up  in  the  milk  and 
strained.  Dr.  Coleman  gives  still  more.  He 
adds  cream  to  the  milk,  increases  the  liquids  and 
gives  sugar  of  milk — that  is,  sugar  that  is  not  so 
sweet.  It  can  be  put  in  the  milk  or  in  lemonade 
and  makes  a  very  agreeable  drink;  and  at  the 
same  time  increases  the  amount  of  nourishment, 
as  it  contains  a  large  amount  of  carbohydrate. 
If  you  give  a  tablespoonful  of  lactose  you  have 
sixty  calories,  and  you  can  put  two  tablespoonf  uls 
in  a  glass  of  lemonade  or  milk  and  thus 
furnish  120  calories.  If  you  give  eight  ounces 
of  milk  with  two  tablespoonfuls  of  lactose,  and 
give  that  eight  times  a  day,  you  get  a  fair  amount 
of  fluid  of  nutritive  value.  Dr.  Coleman  also 
gives  his  patients  eggs,  farina,  rice,  and  toast. 
He  is  not  so  careful  in  abstaining  from  solid 
food,  and  gives  practically  a  liquid  and  semi- 


THE  DIET  IN  ACUTE  DISEASES  53 

solid  diet.  If  milk  is  not  well-borne,  we  have  to 
give  other  things,  barley,  broths,  and  eggs,  and 
so  have  a  good  variety. 

Last  fall  I  had  a  patient  from  out  of  town  with 
typhoid  fever.  He  had  lost  twenty  pounds  of 
flesh  and  had  headaches,  but  no  one  had  made 
a  diagnosis  of  the  condition.  He  came  to  me  for 
a  diagnosis,  for  everyone  thought  he  had  some 
stomach  trouble.  He  complained  of  indigestion 
and  his  appetite  was  poor.  He  was  kept  in  the 
hospital  under  observation  for  a  day  or  two,  and 
we  found  that  he  had  some  temperature,  and 
then  the  diagnosis  of  typhoid  fever  was  easy. 
His  previous  examinations  had  been  made  at  a 
very  early  stage.  In  that  beginning  period 
before  he  had  high  fever,  he  had  lost  twenty 
pounds.  When  he  came  into  the  hospital  he 
said  that  he  could  not  stand  milk,  that  it  disa- 
greed with  him.  So  I  started  him  on  plenty  of 
lemonade  with  milk  sugar,  and  gave  him  eight 
or  ten  eggs  a  day  beaten  up  with  barley  decoc- 
tions, and  butter  in  addition.  That  man  did 
not  lose  another  pound  during  the  entire  course 
of  his  typhoid  fever.  As  soon  as  the  fever  was 
over  the  nourishment  was  pushed  further,  and 
he  gained  right  away,  and  we  sent  him  home  with 


54  LECTURES  ON  DIETETICS 

a  gain  of  fifteen  or  twenty  pounds.  That  was  an 
example  of  what  can  be  done  with  diet  in  typhoid 
fever  for  a  patient  who  cannot  stand  milk.  If 
he  had  been  able  to  take  that,  it  would  have  been 
still  easier  to  give  him  nourishment. 

In  typhoid  fever,  too,  on  account  of  the  length 
of  its  course,  see  that  the  patient  takes  food  say 
every  two  hours.  Give  him  lemonade,  grape- 
fruit, good  chicken  soup,  a  little  ice  cream — that 
is  very  refreshing  and  good.  The  same  principle 
will  apply  to  diseases  of  any  duration  accom- 
panied with  fever. 

Now  we  will  take  up  the  diet  in  chronic  affec- 
tions not  accompanied  with  fever.  The  princi- 
ple which  prevails  here  is  just  the  reverse  of  that 
adapted  for  diseases  of  an  acute  type  and  short 
duration.  In  those  we  said  that  we  need  pay 
no  attention  to  the  amount  of  nourishment 
taken.  It  does  not  matter  that  the  patient  takes 
no  food  for  a  short  time;  he  will  get  over  the 
disease  quickly.  In  diseases  of  a  chronic  nature 
the  first  principle  is  to  see  that  the  patient  takes 
enough  nourishment;  for  unless  he  gets  sufficient 
nutrition  it  does  not  matter  what  else  you  may  do 
— the  diet  may  agree,  the  medicine,  etc.,  be  just 
right — but  the  patient  will  go  down.  He  is 


THE  DIET  IN  ACUTE  DISEASES  55 

bound  to  lose.  He  grows  weaker,  and  finally 
succumbs  not  so  much  to  the  disease  as  to  subnu- 
trition.  No  matter  what  type  of  disease  patients 
have,  they  will  get  tired  of  the  diet.  If  you  do 
not  pay  a  great  deal  of  attention  to  them,  and 
especially  if  the  diet  is  restricted  too  much — 
say  milk  and  eggs,  and  chicken  soup,  and  nothing 
else — in  a  week  or  two  they  get  tired  of  it,  and 
do  not  enjoy  it,  and  the  tongue  gets  coated,  and 
they  take  less,  and  grow  weaker.  So  you  have 
to  see  that  you  give  the  patients  enough  nourish- 
ment. This  principle  comes  first  in  the  plan 
of  treatment,  no  matter  what  the  disease  is. 

If  you  have  to  deal,  for  instance,  with  tuber- 
culosis patients,  who  form  a  large  class  of  these 
chronic  sufferers — if  you  are  not  attentive  in 
seeing  that  they  take  nourishment, — they  will 
take  less  and  less;  they  have  a  little  fever  off  and 
on,  and  may  have  some  catarrhal  condition  of 
the  stomach  or  some  catarrh  of  the  bowels  and 
not  feel  like  eating.  They  are  in  a  state  of 
starvation,  and  very  often  they  succumb  to 
that.  I  will  tell  you  of  a  case  to  show  what  can 
be  done  with  proper  nutrition  in  these  cases.  I 
was  once  called  to  a  patient,  a  lady  with  lung 
trouble,  who  had  suffered  with  diarrhea.  Al- 


56  LECTURES  ON  DIETETICS 

most  anything  she  took  caused  the  bowels  to 
move  right  away.  The  treatment  she  had  been 
having  consisted  in  keeping  from  her  all  kinds 
of  food.  She  had  only  a  little  warm  broth  and 
perhaps  two  eggs  in  24  hours.  She  had  lost  a  great 
deal  of  flesh  and  looked  like  a  skeleton,  and  had 
high  fever,  and  the  question  was  what  could  be 
done  for  her.  When  I  got  there  I  saw  that  she 
would  die  in  no  time,  two  or  three  weeks,  perhaps, 
unless  the  plan  of  diet  was  changed.  So  I  said 
we  must  give  her  nourishment,  diarrhea  or  no 
diarrhea.  We  must  put  in  food.  It  is  better 
to  put  in  and  lose  something,  than  not  to  put 
in  at  all.  So  we  began  to  feed  her.  We  gave 
her  six  or  eight  eggs  a  day,  farina  with  milk, 
rice  with  milk;  and  in  a  few  days  we  started  in 
with  meat  and  mashed  potatoes,  and  we  fed 
her  five  or  six  times  a  day.  She  had  a  nurse  to 
watch  her  and  push  the  feeding,  and  make  her 
take  the  food;  and  by  and  by  she  began  to  rally, 
and  in  a  short  while  she  lost  her  temperature,  and 
her  bowels  were  better,  and  she  began  to  go  out, 
and  gained  thirty  or  forty  pounds,  and  it  was 
three  or  four  years  before  the  lung  trouble  again 
asserted  itself  and  she  died. 

If  there  is  subnutrition  existing,  you  have  to 


THE  DIET  IN  ACUTE  DISEASES  57 

step  in  and  work  against  it.  You  may  say  that 
the  bowels  are  weak  and  cannot  stand  anything. 
You  must  try.  I  do  not  mean  to  say  that  you 
should  not  give  any  remedies.  That  lady, 
besides  the  diet  treatment,  had  some  remedies  to 
bridge  over  the  symptoms.  If  there  is  diarrhea, 
we  will  give  them  some  tannigen,  bismuth,  and 
a  little  codein,  but  they  must  eat  at  the  same 
time. 

It  is  very  much  the  same  in  other  chronic 
conditions — gout,  chronic  rheumatism,  chronic 
Bright's  disease — which  is  a  very  common 
complaint.  Here  the  diet  is  often  too  one- 
sided. A  great  many  physicians  give  milk  and 
milk  alone  in  kidney  troubles  because,  as  you 
know,  the  kidneys  are  not  able  to  keep  back 
albumin  and  make  use  of  it;  and  the  principle  is 
to  keep  away  the  proteid  foods  as  much  as  possi- 
ble in  order  to  save  the  organ.  But  if  the  diet 
is  too  one-sided,  if  the  patient  takes  too  little 
and  does  not  enjoy  it,  he  suffers  from  inanition, 
which  is  worse  than  the  disease. 

In  these  chronic  diseases  you  can  pay  atten- 
tion in  the  plan  of  treatment  to  the  work  of  the 
affected  organ,  to  its  function,  to  see  that  the 
diet  should  not  be  too  heavy  for  the  particular 


58  LECTURES  ON  DIETETICS 

patient.  In  kidney  trouble  you  will  try  to 
eliminate  the  protein  to  some  extent;  give  only 
a  little  meat,  but  the  principle  should  not  be 
carried  to  the  extreme;  you  must  give  in  a  little 
and  adapt  the  diet  in  such  a  manner  that  there 
will  be  a  variety  in  the  food,  and  the  patient 
will  enjoy  it.  Give  them  all  the  cereals  and 
bread  and  a  little  meat.  Restrict  the  particular 
article  that  you  do  not  want,  but  do  not  cut  it 
out  entirely.  The  same  way  with  diabetes 
mellitus — or  sugar  disease.  We  know  that 
sugar  is  not  well-borne;  the  system  cannot  use 
it  up,  and  eliminates  it  through  the  kidneys. 
So,  as  a  rule,  we  put  these  patients  on  animal 
diet,  and  cut  off  starchy  foods;  but  if  you  take 
these  away  entirely  the  patient  gets  tired  of  the 
animal  food  and  grows  weak  and  runs  down. 
Most  physicians  to-day  agree  that  it  is  well  to 
give  them  a  little  starchy  food;  the  system  is 
better  off  with  a  mixed  diet;  but  restrict  the 
undesirable  kind.  Give  them  only  two  rolls  a 
day. 

A  restricted  diet  can  be  carried  out  without 
harm  for  a  short  period  of  time.  You  may  insti- 
tute a  milk  diet  for  a  week  or  two  without  harm, 
but  to  carry  it  on  too  far  is  always  a  mistake. 


THE  DIET  IN  ACUTE  DISEASES  59 

The  system  is  apt  to  suffer  from  a  one-sided 
diet,  no  matter  what  the  disease  is. 

After  these  points  on  diet  in  chronic  diseases, 
we  will  go  on  to  the  diet  in  diseases  of  the  diges- 
tive tract.  With  these,  on  the  whole,  the  same 
principles  prevail  as  in  the  other  diseases. 
Acute  conditions  require  little  attention  to  diet. 
The  diet  should  consist  of  the  finest  foods  in 
liquid  form  and  in  small  quantities.  We  do  not 
have  to  look  out  for  large  amounts  to  cover  the 
loss,  and  we  act  on  that  principle. 

Acute  indigestion,  for  instance.  Some  one 
has  taken  too  large  a  dinner,  has  fever,  and 
vomits.  What  will  you  do  with  the  patient? 
The  best  thing  is  to  do  as  little  as  possible. 
Leave  him  alone.  He  has  no  appetite,  and 
does  not  eat  for  a  day  or  two.  That  is  all  right. 
There  will  be  no  bad  consequences.  In  a  day 
or  two  the  bad  condition  will  be  over  and 
he  will  begin  to  eat  again.  If,  however,  the 
patient  is  in  a  much  reduced  condition,  and 
not  well  nourished,  you  will  have  to  give 
some  nourishment — clam  broth,  milk,  tea  and 
sugar.  Give  them  light  nourishment,  and  they 
will  get  better. 

The  same  obtains  in  diseases  of  the  bowels — 


60  LECTURES  ON  DIETETICS 

for  instance,  in  severe  diarrhea.  Leave  the 
patients  alone.  Give  them  a  little  tea,  warm 
soup,  until  the  acute  attack  has  subsided,  and 
then  begin  to  nourish  them  again. 

The  chronic  diseases  of  the  digestive  tract 
may  be  divided  into  two  large  groups — one  in 
which  there  is  organic  disease  present,  like 
ulcer  or  cancer;  and  the  other  in  which  there  are 
mild  inflammatory  conditions,  catarrh,  etc., 
or  functional  disturbances  present. 

In  regard  to  organic  disease,  ulcer  of  the 
stomach,  for  instance,  there  we  make  a  division 
between  the  two  stages — the  acute  state  of  the 
ulcer  where  there  are  more  pronounced  symp- 
toms, severe  pain  and  vomiting;  and  the  chronic 
stage,  the  period  of  acquiescence,  where  the 
condition  is  not  so  active.  The  treatment  must 
be  different  in  the  two  periods.  In  the  acute 
stage,  again  rest  is  the  principal  thing.  If  the 
patient  has  a  hemorrhage,  keep  him  on  rectal 
alimentation — practically  starvation,  and  saline 
injections;  some  of  the  fluid  is  taken  up  by  the 
system;  perhaps  one-third  or  a  quarter  of  the 
nutritive  material  introduced  through  the  bowel 
can  be  taken  up,  but  it  is  essential  that  the 
digestive  tract  should  rest  for  five  or  six  days. 


THE  DIET  IN  ACUTE  DISEASES  61 

Then  begin  with  mild  liquid  diet  by  mouth,  or 
duodenal  feeding.  That  represents  a  method 
of  feeding  which  covers  the  losses  and  gives  rest 
to  the  stomach. 

But  when  the  acute  stage  is  over  and  the  chronic 
form  has  begun,  then  you  have  to  look  out  for  a 
sufficient  amount  of  food.  The  food  should  not, 
however,  be  too  irritating  to  the  system.  In 
cancer  of  the  stomach  we  have  to  look  out  that 
the  patient  is  well  nourished,  and  we  give  him 
fine  articles  of  food,  and  if  it  is  impossible  to  put 
the  food  in  the  stomach  normally,  as  in  cancer  of 
the  pylorus,  a  gastroenterostomy  is  done  to 
make  nourishment  possible;  but  again  we  have  to 
see  that  the  food  given  does  not  irritate  the 
particular  disease.  A  patient  with  cancer  can- 
not stand  the  ordinary  food,  but  we  have  to 
give  him  as  much  of  a  light  food  as  we  can,  and 
as  long  as  we  can. 

In  the  second  group  of  cases,  the  functional 
diseases  of  the  stomach  and  intestines,  it  is  very 
important  to  feed  them  properly.  Formerly 
the  principle  prevailed  that  all  dyspeptic  indivi- 
duals should  be  put  on  a  diet,  and  by  that  was 
meant  very  little  of  the  finest  food — a  milk  diet, 
or  soup,  or  perhaps  a  little  meat.  There  was  a 


62  LECTURES  ON  DIETETICS 

physician  in  the  city  who  used  to  give  his  patients 
meat  and  broth,  and  perhaps  a  few  slices  of 
toast — nothing  else;  and  that  particular  diet 
was  carried  out  with  a  great  many  patients, 
sometimes  with  some  benefit,  but  oftentimes 
with  a  great  deal  of  harm.  In  Germany  to-day 
that  theory  of  dieting  a  patient  still  prevails, 
more  so  than  I  like.  I  often  have  such  patients 
come  to  me,  and  I  tell  them  to  go  ahead  and 
eat  like  other  people,  only  to  exclude  this  or 
that;  and  by  and  by  they  come  to  me  and  ask  if 
they  should  not  be  put  on  a  diet, — meaning  to 
be  kept  away  from  food.  But  in  my  opinion, 
that  is  the  worst  thing  for  them  to  do. 

It  is  my  conviction  that  the  principle  that 
prevailed  in  former  years  of  putting  every — 
patient  with  dyspeptic  symptoms  on  a  restricted 
diet — was  a  wrong  one.  A  great  many  persons 
who  suffer  from  minor  ailments  of  the  digestive 
system  keep  away  from  food.  Many  physicians 
think  that  starchy  foods  are  harmful  for  such 
patients,  and  forbid  them  to  take  bread  and 
potatoes.  All  vegetables  contain  starchy  food, 
so  they  are  allowed  only  a  little  bread  and  per- 
haps only  a  little  meat,  and  they  do  not  enjoy 
their  food,  and  symptoms  of  inanition  develop, 


THE  DIET  IN  ACUTE  DISEASES  63 

and  many  of  these  invalids  ultimately  die  of 
improper  feeding. 

The  proper  principle  is  not  to  forbid  anything 
but  what  is  sure  to  cause  harm.  Everything 
else  should  be  allowed.  These  patients  should 
be  given  great  liberty  in  their  diet,  because  it  is 
of  the  greatest  importance  to  look  out  that  these 
chronic  dyspeptics  get  a  sufficient  amount  of 
food.  That  is  the  principle  upon  which  I  act, 
and  the  more  I  practice  it  the  more  am  I  con- 
vinced that  it  is  the  right  way  of  treating  these 
patients. 

One  of  my  patients  was  a  physician  from  Texas 
who  had  some  dyspeptic  troubles,  and  he  got 
worse  and  worse,  until  he  had  lost  forty  pounds 
of  flesh,  and  finally  had  to  give  up  his  practice 
on  account  of  his  inability  to  take  food.  He 
came  to  this  city,  where  he  had  a  good  friend, 
a  nerve  specialist,  who  invited  him  to  stay  with 
him  at  his  summer  residence  in  Greenwich  and 
offered  to  look  after  him;  but  the  man  continued 
to  grow  worse.  He  could  not  take  any  food,  and 
still  lost  flesh,  and  having  had  to  give  up  his 
business  he  was  constantly  worrying,  and  his 
nervous  symptoms  did  not  improve.  Finally 
he  came  to  me  for  advice,  and  began  by  telling 


64  LECTURES  ON  DIETETICS 

his  story.  He  could  not  take  any  toast,  for  that 
caused  symptoms  right  away;  he  could  not  take 
meat,  for  it  made  him  vomit;  he  could  not  take 
that,  for  it  gave  him  a  headache,  and  so  on — he 
could  not  take  anything.  He  thought  that  I 
was  going  to  be  guided  by  his  opinion,  but  he 
was  mistaken;  if  I  had  done  that,  he  would  be 
dead  now.  I  told  him  that  if  he  wanted  to 
be  treated  by  me,  he  would  have  to  do  as  I 
directed,  and  leave  his  own  opinions  alone.  So 
we  began.  His  disease  as  such  did  not  amount 
to  much.  He  had  an  atonically  dilated  stomach, 
and  was  in  a  run-down  condition,  but  had  no 
organic  disease.  We  began  to  feed  him,  and 
I  had  to  make  him  eat  contrary  to  his  own 
convictions.  I  had  to  give  him  bromides  at 
first,  to  act  as  a  sedative,  but  he  did  as  I  said, 
and  began  to  eat,  and  he  regained  his  flesh,  and 
is  now  practicing  as  before,  and  is  convinced 
that  he  can  eat  everything. 

A  great  fear  of  food — "sitophobia" — develops 
in  many  of  these  dyspeptics,  perhaps  because  of 
some  disturbances  they  had  experienced  and 
because  they  have  been  told  to  keep  away  from 
all  kinds  of  food,  and  when  they  do  take  it  that 
fear  gives  them  more  symptoms,  so  that  the 


THE  DIET  IN  ACUTE  DISEASES  65 

patient  is  worse  if  he  has  to  eat  something;  he  is 
afraid  to  sit  at  the  table,  and  certainly  he  must 
suffer.  That  condition  must  be  combated — the 
aversion  to  the  sight  of  food  and  the  fear  of  it. 
You  must  tell  them  that  even  if  there  is  some 
pain,  they  must  take  the  food  and  get  out  of 
that  condition.  It  is  better  to  eat  and  suffer 
than  not  to  eat  and  not  to  suffer.  You  cannot 
live  without  food.  That  is  the  first  and  fore- 
most principle.  — 


LECTURE  IV 

THE   DIET  IN   CHRONIC   AFFECTIONS   OF  THE 

DIGESTIVE  TRACT  (CONTINUED) 
> 

To-day  we  will  continue  with  the  subject  of 
diet  in  the  treatment  of  diseases  of  the  digestive 
organs,  of  a  chronic  nature.  I  mentioned  in  my 
last  lecture  that  severe  illness  and  organic  affec- 
tions have  to  be  treated  differently  in  regard  to 
diet  from  those  troubles  which  are  more  or  less 
of  a  functional  character,  and  which  are  in  the 
majority. 

We  will  subdivide  this  large  class  of  functional 
disturbances,  taking  the  stomach  first,  into 
three  divisions: — one  in  which  the  gastric  secre- 
tions are  increased  (hyperacidity);  the  second, 
in  which  gastric  secretions  are  normal,  and 
third,  in  which  they  are  diminished  (hypoacidity). 
In  hyperacidity — too  much  acidity,  too  much 
gastric  juice — we  again  have  several  subdivi- 
sions: One,  continuous  hypersecretion  and  the 
other,  increased  secretion  during  digestion,  i.  e.t 
digestive  hypersecretion. 

66 


THE  DIET  IN  CHRONIC  AFFECTIONS     67 

The  second  large  group  is  that  of  rather  nor- 
mal secretion  and  the  third,  is  diminished  secre- 
tion, or  absent  secretion.  We  have  to  deal  with 
all  of  these  conditions.  First,  we  will  take  the 
group  in  which  the  gastric  secretion  is  increased, 
which  in  my  experience  forms  more  than  half, 
or  about  half,  of  most  functional  diseases  of  the 
stomach.  Up  to  within  recent  years,  the  diet 
question  in  the  class  of  cases  where  the  acid 
secretion  is  increased  has  been  in  a  rather  unset- 
tled state.  There  are  a  great  many  physicians 
of  repute  who  maintain  that  all  starchy  food 
should  be  forbidden  to  these  patients,  because 
it  has  been  found  that  the  symptoms  in  these 
cases  are  rather  increased  after  the  ingestion  of 
starchy  foods.  The  physicians  who  represent 
that  idea  have  gone  so  far  as  to  designate  this 
class  of  cases  as  " starchy  dyspepsia,"  or  "amyla- 
ceous dyspepsia,"  indicating  that  they  ascribe 
so  much  importance  to  this  particular  thing 
that  they  found  it  worthy  to  name  it  in  this  way 
— and  have  arranged  the  diet  accordingly.  Ac- 
cording to  these  physicians,  the  diet  for  hyper- 
chlorhydria  consists  in  allowing  meats  and  fats, 
taking  away  entirely  the  carbohydrates.  The 
Salisbury  regime,  which  I  have  mentioned 


68  LECTURES  ON  DIETETICS 

before — meat,  broths,  and  little  toast — is  also 
representative  of  that  idea — the  starch-free  diet. 

Now  while  it  is  found  that  a  patient  with  hyper- 
chlorhydria  when  put  upon,  say,  eggs,  and  a 
little  meat  and  nothing  else  may  be  relieved  of 
his  symptoms — may  lose  his  pain,  belch  less, 
and  may  be  more  comfortable — while  all  this 
is  true  at  first,  I  do  not  think  a  real  cure  will 
take  place  if  that  diet  is  extended  too  long. 

Now,  again,  there  are  a  number  of  physicians 
who  represent  the  opposite  view.  Pawlow, 
the  St.  Petersburg  physiologist,  has  made  many 
experiments  on  animals,  with  the  stomach 
arranged  so  that  it  can  be  looked  into  and  exam- 
ined, and  has  found  that  meat  and  all  nitrogen- 
ous foods  have  a  tendency  to  increase  the  flow 
of  gastric  juice,  while  vegetables,  the  carbo- 
hydrates, and  fats  have  a  tendency  to  diminish 
gastric  secretion.  (In  parenthesis  I  will  mention 
that  Bickel  experimenting  in  a  similar  manner 
as  Pawlow  put  up  food  groups  distinguishing 
between  weak  and  strong  secretory  stimulants, 
as  follows: 

1.  Weak  secretory  stimulants. 

Beverages:  plain  water;  alkaline  water  with- 
out C02J  tea;  rich  cacao;  milk;  cream. 


THE  DIET  IN  CHRONIC  AFFECTIONS     69 

Spices:  sodium  chloride  in  0.9%  solution. 

Foods:  dissolved  or  finely  emulsified  albumi- 
nates,  as  for  instance  fluid  egg  albumen,  solu- 
tions and  suspensions  of  lactalbumin,  casein, 
glidin;  pure  carbohydrates,  as  sugar  and  starch; 
fresh  wheaten  bread;  all  kinds  of  fat;  well 
boiled  meat;  ragouts  of  boiled  meat  with  fatty, 
but  unseasoned  gravy  (especially  the  fat  and 
white,  but  not  salted  meats,  as  fresh  fish, 
chicken,  calf,  pork);  pureed  or  stewed  sweet 
fruits,  likewise  vegetables  prepared  in  the  same 
way  with  butter,  as  for  instance  potato,  rice, 
farina,  sago,  asparagus,  red  cabbage,  cauliflower, 
spinach,  white  beets,  carrots,  cucumbers;  soups 
prepared  without  meat  extracts  but  boiled  in 
plain  water,  like  vegetable  soups  or  bread  soups 
or  oatmeal  gruel;  dessert  dishes  prepared  of 
beaten  egg  albumin,  cream  with  rice,  farina, 
mondamin,  etc. 

2.  Strong  secretory  stimulants. 

Beverages:  All  alcoholic  and  carbon  dioxid 
containing  beverages,  as  for  instance  wine,  beer, 
the  mineral  and  saline  waters  containing  CO2; 
coffee  and  caffein  free  coffee,  all  coffee  substitutes, 
fat  free  cocoa,  and  skimmed  milk. 

Spices:  sodium  chloride,  excepting  the  0.9% 


70  LECTURES  ON  DIETETICS 

solution;  mustard;  cinnamon;  cloves;  pepper; 
paprica;  all  soup  seasonings. 

Foods:  All  broiled  vegetables  and  animal 
foods;  the  yolk  of  the  egg,  coagulated  egg  albu- 
men, raw,  broiled  or  slightly  boiled  meat,  espe- 
cially raw  and  slightly  broiled  meat,  principally 
the  dark  meats;  all  salty  and  smoked  meats 
inclusive  fish,  prepared  in  the  same  manner; 
meat  extracts  and  all  dishes  prepared  with 
them,  like  bouillon,  bread,  especially  brown 
bread  and  pumpernickel;  toasted  bread;  all 
vegetables  mentioned  in  rubrik  1,  (if  steamed 
and  prepared  in  their  own  juices  and  not  served 
as  purees.) — This  led  the  way  to  a  second 
arrangement  of  the  food  in  cases  of  hyperchlor- 
hydria.  These  physicians  said  that  if  we  give 
these  patients  a  diet  rich  in  animal  food,  the 
gastric  secretion  is  increased  and  the  stomach  is 
overstimulated.  So  they  have  started  the  oppo- 
site principle  of  feeding,  and  said  that  we  should 
keep  away  all  animal  food  from  patients  with 
hyperchlorhydria,  and  give  them  a  strictly 
vegetable  diet,  with  butter. 

Both  parties  show  successes  in  their  treatment; 
both  have  their  failures — which  is  quite  natural, 
like  everything  else.  Now,  the  question  is, 


THE  DIET  IN  CHRONIC  AFFECTIONS     71 

what  shall  you  do.  If  you  read  the  books,  one 
will  forbid  all  starchy  food  to  these  persons; 
almost  all  vegetables  too.  The  other  will 
teach  just  the  opposite  for  the  same  class  of  cases. 
My  answer  to  this  is  that  neither  of  them  is 
altogether  right;  for,  as  I  told  you  a  week  or 
two  ago,  any  diet  that  is  arranged  for  a  long 
period  of  time  must  contain  all  the  three  groups 
of  nourishment  we  need,  proteins,  carbohydrates, 
and  fats.  While  we  can  arrange  a  diet,  a  bill 
of  fare,  in  such  a  manner  that  one  group 
should  predominate  and  the  others  be  lessened,  we 
cannot  exclude  any  one  of  these  three  cardinal 
nutritious  groups  from  any  diet.  That  is  a 
cardinal  point.  Wemust  giyeaj^atient^^ll 
these  three  things;  but  where  there  is  toojnuch 
secretion  a  starchy  food  is  not  so  well  used  up, 
and  you  can  give  that  patient  less  starchy  food, 
and  more  fat  and  albuminates. , J3o,  in  actual 


give,  them^meat  in__a-Jargeamount  and  fats, 
and  diminish  the  starchy  food.  I  tell  them  that 
thev^jshould  not  eat  too  many^j^otatoeSj^piLt 
no  restriction^pnT^pTead1^  for  that  is  j5uch_an 
important  article  of  food,  andJL§orae  patients 


72  LECTURES  ON  DIETETICS 

do  not  eat  bread  they  cannot  eat  anything — and 
give  them  all  plenty  of  butter. 

The  reason  why  starch  can  be  given  to  these 
patients  is,  first,  that  even  if  it  does  not  change 
so  quickly  (the  acid  gastric  secretion  when 
reaching  a  certain  height,  checks  the  ptyalin 
action  of  the  saliva,  in  the  stomach),  the  pan- 
creatic juice  contains  a  very  active  ferment  for 
the  conversion  of  starch  into  sugar  and  ferments 
for  the  conversion  of  fats  and  albuminates;  and 
if  the  starch  digestion  is  inhibited  in  the  stomach 
it  will  be  finished  further  on  in  the  digestive  tract. 
Another  reason  is  that  if  the  acidity  is  so  great 
as  to  prevent  the  change  of  starch  into  sugar, 
we  can  give  these  patients  alkalies  to  diminish 
the  acidity,  and  that  is  better  than  to  take  away 
the  starch;  it  is  better  to  give  a  remedy  than  to 
take  away  the  food. 

So  the  diet  in  these  cases  of  hyperchlorhydria 
should  be  a  liberal  one.  We  must  take  away 
all  highly  spiced^u^ta^c^sj_a^id_jio_t_^iy£_the^ 
too  much  of  thetougher  meats^such  as  beef, 
pork,  venison^  but  a  liberal  diet  of  chicken, 
lamb_cliQps,  or  the  tender  meats,  and_g>lenty_of 
milk,  Jgutter  and  eggs,  bread  and  cereals,  and 


THE  DIET  IN  CHRONIC  AFFECTIONS      73 

rather    restrict    potatoes    and    other    starchy 

substances. 

— -~" — T~ 

We  will  now  consider  those  cases  where  there 

is  continuous  hypersecretion,  the  group  in  which 
the  stomach  continues  to  secrete  juice  even  if 
there  is  no  food  present.  Usually  we  find  this 
condition  in  ulcers  of  the  pylorus;  rarely,  in  cases 
of  neurotic  disturbances,  either  due  to  organic 
nervous  diseases,  central  lesions,  or  sometimes 
merely  functional  in  character. 

What  will  you  do  in  this  group?  Here  fre- 
quent eating  is  of  great  importance.  Try  to 
make  use  of  the  gastric  juice  which  is  given  by  the 
stomach  anyway.  It  irritates  the  mucous  mem- 
brane and  makes  the  patient  uncomfortable — 
but  if  you  put  in  some  food,  and  especially 
albuminates  which  have  a  tendency  to  enter 
into  combination  with  the  acid — the  acidity  in 
the  stomach  is  diminished  and  that  gives  them 
relief.  These  patients  tell  you  that  they  have 
pain  three  hours  after  eating.  If  they  eat,  the 
pain  is  better.  The  acidity  is  reduced  by  the 
ingestion  of  food.  The  water  and  the  albu- 
minates in  the  food  bind  the  acid,  so  that  it  is 
not  only  diminished  (diluted)  but  some  is  taken 
away  (partly  neutralized).  Some  of  these 


74  LECTURES  ON  DIETETICS 

patients  wake  up  early  in  the  morning.  The 
acidity  is  too  great  for  the  stomach.  If  they 
put  in  food — eat  breakfast,  they  feel  all  right. 
So  frequent^  eating  is  ji,  cardinal  point  in__the 
treatment  of  these  cases. 

Fats  have  a  tendency  to  inhibit  j*astri<L  secre- 
tion, and  are  to  be  recommended  in  aU_Jhejse 
classes  of  hypercAlorhydria^^and  ^continuous 
hypersecretion. 

ow,  we  will  take  up  the  cases  in  which 
the  gastric  secretion  is  normal.  The  symp- 
toms may  be  of  a  high  character.  The  patient 
complains  of  all  kinds  of  things — pain,  eruc- 
tations, loss  of  appetite,  etc.  This  is  the  group 
designated  as  nervous  dyspepsia.  The  symp- 
toms are  distressing,  but  still  we  find  nothing 
radically  wrong.  We  cannot  find  any  deviation 
from  the  normal,  and  still  the  patient  complains, 
and  so  we  ascribe  the  condition  to  some  nervous 
phenomena  which  we  do  not  exactly  under- 
stand. These  cases  have  to  be  treated  differ- 
ently. They  can_£a^^^vjthing^and _  should^  be 
made  to  eat  everything^  they  shoulpVbe_given  a^ 
liberal  diet;  no  restrictipns^at  all  in  these  cases^ 
Very  often  these  patients  with  nervous  dyspepsia 
eat  lightly,  and  if  kept  away  from  food  they 


THE  DIET  IN  CHRONIC  AFFECTIONS     75 


would  never  get  well;  but  if  you  change  their 
habits  of  eating,  the  change  should  not  be  made 
too  abruptly.  If  patients  have  been  on  a  strict 
diet  for  a  long  time,  you  cannot  bring  on  a 
change  in  a  day.  A  patient  who  has  been  living 
on  milk  and  crackers  for  two  years  if  put  at  the 
table  and  given  a  good  meal — even  if  the  stom- 
ach is  good — will  have  trouble.  The  stomach 
is  not  used  to  it.  You  should  take  a  few  days, 
or  even  a  week,  and  gradually  change  the  diet, 
until  the  patient  is  put  in  such  a  condition  that 
he  eats  everything.  All  of  these  cases  of  nervous 
dyspepsia  should  eat  everything,  but  make  the 
change  to  the  regular  way  of  living  slowly. 

Now,  we  come  to  the  third  group,  in  which 
just  the  reverse  of  the  first  group  exists;  the* 
gastric  secretion  is  diminished — and  ultimately 
we  will  take  the  group  in  which  there  is  no 
gastric  juice  at  all. 

In  chronic  gastric  catarrh  there  is  a  diminu- 
tion of  the  acidity,  and  in  functional  nervous 
disorders,  disorders  of  a  depressed  character, 
the  stomach  works  poorly  and  the  acidity  is 
diminished.  In  all  these  cases  the  vegetable 
foods  should  predominate,  and  not  much  meat 
should  be  given.  Meat  should  be  restricted, 


v 
$*/' 


76  LECTURES  ON  DIETETICS 

and  fats  as  such  should  not  be  given  in  large 
quantities,  for  they  have  a  tendency  to  inhibit 
secretion.  Meat,  on  the  other  hand,  has  a 
tendency  to  increase  secretion,  but  if  too  much 
is  given  it  creates  a  disturbance  —  so  we  give 
enough  meat,  and  less  fat. 

Now,  all  these  questions  have  been  worked 
out  by  the  physiologists,  but  we  cannot  take 
their  findings  right  away  into  the  clinic  and  say, 
"We  go  according  to  them."  It  is  only  if  they 
have  been  proven  to  do  good  in  practice  that 
we  can  adopt  them.  Until  then,  we  cannot  go 
by  them  alone.  In  Germany  especially,  many 
clinicians  act  too  much  on  these  physiological 
experiments.  They  at  once  give  a  diet  accord- 
ing to  these  rules.  But  that  is  not  the  best  way. 
It  is  best  to  go  by  what  we  find  to  be  of  clinical 
value,  and  to  leave  the  theories,  as  such,  alone. 
If  we  find  something  practical,  and  this  corre- 
sponds to  a  certain  physiological  theory,  so  much 
the  better. 

Now  we  come  to  the  class  of  cases  in  which 
there  is  no  gastric  secretion,  achylia  gastrica. 
'  That  is  a  large  group.  These  patients  have  no 
organic  disease,  and  yet  have  distressing  symp- 
toms. It  is  the  result  of  something  else.  The 


THE  DIET  IN  CHRONIC  AFFECTIONS      77 

condition  is  easily  managed  and  the  dietetic 
treatment  here  plays  a  great  part.  The  food  is 
changed  very  little  in  the  stomach  in  these  cases, 
for  there  is  no  gastric  juice.  Not  only  the  albumi- 
nates  but  also  the  starch  and  fats  are  unchanged. 
Starch  as  such  would  change  in  such  a  stomach, 
but  the  starch  is  usually  enclosed  in  a  membrane 
of  plant  albumin,  and  this  little  membrane  or  coat- 
ing which  surrounds  the  starch  is  usually  opened 
by  the  gastric  juice ;  but  in  cases  of  achy  Ha  there  is 
no  gastric  juice,  and  the  ptyalin  cannot  reach 
the  starch  and  enter  it;  and  that  is  the  reason 
why  starch  cannot  change  in  cases  of  achylia. 
If^£u^wajitth£_sto 

see  that  the  particle^ofjood_are^  entirely^  broken 
up,  pulverized  almost;  that^as_£_tendency_to 
open  up  the  little  cells  in  such  a  way  as  to  reach 
the  secretion. 

Another  reason  why  these  patients  should  have 
their  food  prepared  in  a  finely  divided  form  is 
again  the  circumstance  that  there  is  nothing  in 
the  stomach  to  help  the  dissolution  of  these 
particles.  Normally,  the  gastric  juice  dissolves 
the  connective  tissue  surrounding  the  meat 
and  prepares  it  for  further  digestion  in  the  intes- 
tine. In  a  case  of  achylia  gastrica  the  meat 


78  LECTURES  ON  DIETETICS 

which  is  swallowed  remains  unchanged  until  it 
reaches  the  duodenum. 

The  connective  tissue  surrounding  the  meat 
fibers  does  not  disappear,  and  the  latter  reaches 
the  duodenum  in  the  same  shape  in  which  it  was 
ingested.  It  looks  as  if  it  had  been  masticated 
and  spit  out.  Some  of  you  have  seen  me  take 
out  such  stomach  contents  which  look  exactly  as 
if  the  food  had  been  chewed  a  little  and  then 
brought  out.  So  the  mechanical  division  of  the 
food  is  important  in  these  patients  with  achylia. 
If  the  food  comes  into  the  duodenum  unchanged 
it  creates  symptoms — pain,  etc.,  and  the  patients 
suffer  from  catarrh  of  the  bowels,  frequently 
causing  constipation  alternating  with  diarrhea. 
Not  only  in  the  stomach  but  also  in  the  intes- 
tines the  food  continues  to  be  an  irritant. 

So  the  foods  in  these  cases  should  be  finely 
divided  mechanically.  Acc^rdingly__we__giye 
these  patients 
lentil  soup,  mashe^ 
boiled  eggs.  If  you  give  them  hard  boiled 

— *• "y       _^gf r,      •*  "i- 

eggs,  they  will  remain  in  the  stomach,  but  raw 
eggs  which  are  semi-liquid  will  slip  through. 
We  &iye  the^ejp^tiejQtsjve^jittle^ieat,  for  the 
reasons  which  I  have  already  mentioned.  I 


THE  DIET  IN  CHRONIC  AFFECTIONS     79 

have  found  very  often  that  by  such  a  strict 
diet  of  liquid  and  semi-solid  food — they  must 
be  told  to  masticate  their  food  well — that  they 
can  get  along  very  well.  The  diet  brings  on  a 
great  improvement. 

But  shall  we  let  these  patients  continue  on 
such  a  diet  indefinitely?  No.  The  principle 
to  which  I  have  already  referred  is  important 
not  only  in  the  other  groups  but  here  also — that 
a  diet  deviating  much  from  the  normal  should 
not  be  kept  up  indefinitely.  Our  tendency 
should  be  to  strengthen  the  digestive  tract  and 
harden  it,  and  bring  it  to  such  a  state  that  it  can 
manage  normal  food.  No  matter  whether 
the  constitutional  condition  is  changed  or  not — 
we  may  not  be  able  to  remove  it,  but  if  we  can 
change  the  patient's  manner  of  living  so  that  he 
can  live  like  other  people, — we  have  attained 
what  we  want.  We  want  to  take  the  patient 
away  from  invalidism,  and  from  anything  that 
tends  to  keep  him  in  that  condition. 

Here  too,  in  achylia  gastrica,  while  at  first  we 
are  strict  in  having  these  patients  live  on  fine 
foods,  step  by  step  we  introduce  other  things, 
and  arrange  so  that  in  time  they  can  digest 
ordinary  diet.  It  takes  time — a  month,  per- 


80  LECTURES  ON  DIETETICS 

haps  two  or  three  months, — but  that  should  be 
the  aim.  I  usually  find  that  these  patients 
with  achylia  can  live  twenty,  thirty,  or  forty 
years  and  even  become  normal  individuals.  If 
you  can  bring  them  to  a  state  where  they  can 
enjoy  a  normal  meal,  they  are  practically  well. 
The  intestine  is  strengthened  in  such  a  way  that 
it  learns  to  do  the  work  which  the  stomach  ought 
to  do.  That  can  be  done  by  a  gradual  change 
of  diet,  increasing  it  step  by  step.  This  princi- 
ple must  extend  to  all  chronic  conditions. 

Another  point  of  great  importance.  Many 
of  these  dyspeptic  individuals — no  matter  what 
the  character  of  their  digestive  disease — have 
been  forbidden  a  great  deal,  and  have  lived  with 
so  little  nourishment  that  they  are  in  a  condi- 
tion of  subnutrition.  They  are  run  down,  and 
cannot  do  anything;  they  lead  lives  of  invalidism, 
lie  on  a  lounge,  etc.,  and  many  of  them  gradually 
die  of  starvation.  The  nerves  are  not  nourished; 
all  the  organism  is  in  a  state  of  inanition,  like  a 
business  in  which  there  is  too  little  money. 
Such  a  business  cannot  go  on  well.  So  with  the 
organism.  If  the  body  has  not  enough  food,  it 
takes  a  little  of  its  own  fat  and  muscle,  and  that 
will  not  do.  That  is  what  these  patients  really 


THE  DIET  IN  CHRONIC  AFFECTIONS     81 

represent.  They  are  dizzy  and  have  no  appetite, 
and  are  weak — all  symptoms  of  inanition.  If 
we  treat  these  patients  by  giving  them  a  diet 
on  which  they  have  just  enough  to  lead  their 
existence,  they  will  never  get  well,  for  they 
remain  in  that  weakened  condition.  But  if  we 
can  feed  them  up — increase  their  diet,  give  them 
more  food  than  they  need,  build  them  up — we 
can  get  them  well.  The  question  in  all  these 
cases  is — can  you  do  it?  My  answer  would  be 
that  in  nine  cases  out  of  ten,  or  perhaps  still 
more,  you  can  do  it,  provided  there  is  no  organic 
lesion  present — no  cancer,  no  obstruction;  sim- 
ply a  lack  of  nutrition,  some  functional  disturb- 
ance. From  my  experience,  I  would  say  that 
in  more  than  nine  cases  out  of  ten  you  can 
succeed  in  changing  such  an  individual  and 
building  him  up. 

The  question  is:  How  to  do  it?  I  answer: 
First  change  the  diet,  and  change  it  gradually,  as 
I  said  before.  You  cannot  do  it  in  a  day.  The 
intention  is  to  have  the  diet  similar  to  what  the 
patient  has  been  having,  only  we  make  it  more 
nutritious  gradually.  Suppose  you  have  suc- 
ceeded in  changing  it  and  the  patient  now  takes 
three  meals  a  day,  and  you  want  him  to  gain 


82  LECTURES  ON  DIETETICS 

flesh.  This  applies  not  only  to  diseased  indi- 
viduals, but  to  any  one.  We  have  a  number  of 
thin  persons  here,  some  of  whom  might  like 
to  gain  a  little  flesh.  Some  one  may  want  to 
gain,  but  he  says,  "my  family  is  thin,  we  are  all 
thin;  I  cannot  do  anything."  That  is  what 
people  usually  say:  "We  are  all  thin;  that  is  the 
way  we  grew  up." 

But  such  people  can  be  made  stouter.  We. 
can  make  them  gain  if  they  carry  out  what 
is  needed.  Such  a  person  takes  for  breakfast, 
say  a  cup  of  coffee,  an  egg,  and  a  roll.  If  we 
want  him  to  gain,  we  must  try  to  make  this  bill 
of  fare  more  nutritive.  Instead  of  coffee,  we 
say,  take  two  parts  of  milk  and  one  part  of  coffee; 
then  he  has  more  milk.  Then  we  tell  him  to 
take  a  great  deal  of  butter  on  his  bread,  and  to 
take  two  eggs  instead  of  one,  and  butter  with 
them.  Then  for  lunch,  do  the  same  way. 
Make  the  foods  which  he  has  been  taking  more 
nutritious,  take  more  cream,  more  sugar.  If 
the  patient  has  been  just  maintaining  his  weight 
all  the  time  on  his  former  diet,  make  the  drinks 
more  nutritious.  In  a  week  or  two  he  will 
report  that  he  has  gained  a  pound ;  if  he  keeps  it 
up,  he  will  gain  more — if  he  keeps  up  the  same 


THE  DIET  IN  CHRONIC  AFFECTIONS      83 

amount  of  work.  Now  he  begins  to  take  more 
milk  and  more  butter.  What  he  does  not  need 
to  maintain  his  balance  goes  to  make  more 
flesh.  If  you  want  some  one  to  gain  and  he  has 
been  walking  three  miles  a  day,  and  it  is  essen- 
tial that  he  should  gain  weight,  have  him  take 
between  meals  a  glassful  of  milk  and  bread  and 
butter.  At  first  he  will  tell  you  that  his  appetite 
is  not  so  good  for  the  next  meal,  but  he  will  soon 
get  used  to  it.  That  is  practically  the  way  I 
proceed  with  these  patients  where  it  is  necessary 
to  build  them  up.  Have  them  take  their  regular 
meals  and  add  two  small  meals  in  between.  I 
lay  much  stress  on  the  amount  of  butter.  Tell 
them  to  eat  a  quarter  of  a  pound  of  butter  a  day. 
A  quarter  of  a  pound  of  butter  contains  almost 
a  thousand  heat  units.  If  he  eats  a  quarter  of 
a  pound  of  butter  a  day,  he  has  a  thousand  heat 
units  added,  which  he  does  not  need  for  living, 
and  it  goes  into  fat.  Butter  is  easily  taken  up — 
•you  can  put  it  in  oatmeal,  eggs,  on  bread,  etc. 
The  patient  enjoys  it,  and  eats  more.  So  butter 
is  a  very  important  article  of  food,  in  those  cases, 
where  it  is  essential  to  increase  the  body  weight, 
and  it  is  essential  in  many  instances. 

If  a  man  is  all  right,  leads  an  active  life,  that 


84  LECTURES  ON  DIETETICS 

is  all  right.  But  if  he  is  very  thin,  barely  covers 
his  expenses,  if  he  gets  sick  he  has  not  much  to 
draw  upon,  so  it  is  well  to  have  a  reserve  fund  of 
flesh  to  draw  upon. 

The  same  principle  can  be  turned  around. 
Normally,  we  should  be  just  right — not  too 
stout,  not  too  thin.  There  should  be  harmony 
and  symmetry  in  our  organism,  and  if  a  person 
looks  just  right,  you  can  judge  by  the  appearance 
that  he  is  all  right.  But  if  you  grow  clumsy 
and  can  hardly  move  about,  that  is  not  well. 
Can  you  reduce  the  weight  of  such  persons  by 
diet?  Yes.  But  there  again  is  a  point  of  great 
importance,  that  is,  exercise.  If  you  have  a  stout 
fellow  taking  food  that  just  keeps  him  in  his 
balance — he  does  not  gain  and  he  does  not  lose, 
and  you  want  him  to  lose  and  still  you  do  not 
want  him  to  reduce  his  bill  of  fare  too  much,  for 
if  you  make  him  take  too  little  he  may  have  some 
heart  complications — increase  his  exercise.  If 
he  is  used  to  walking  two  miles  a  day,  make  him 
walk  three  or  four,  and  then  five,  or  make  him 
climb  a  mountain,  and  with  the  same  food  he 
begins  to  lose  gradually.  That  is  the  best  way 
of  reducing  flesh ;  but  if  you  see  that  he  is  eating 
too  much,  eats  enough  for  three  people,  then 


THE  DIET  IN  CHRONIC  AFFECTIONS     85 

reduce  his  food.  Instead  of  taking  milk,  give 
him  coffee  and  tea  for  breakfast,  and  take  away 
the  butter;  and  if  he  eats  between  meals,  tell 
him  to  have  three  meals  instead  of  five.  Treat 
him  the  opposite  way  from  the  management  of 
increasing  weight  and  you  can  succeed  in  reduc- 
ing flesh. 

People  can  increase  or  diminish  bodily  weight 
at  will,  provided  these  instructions  are  carried 
out.  It  is  far  more  difficult,  however,  to  make  a 
stout  man  thin  than  to  make  a  thin  man  stout, 
because  what  you  want  is  not  to  the  fancy  of  the 
corpulent  man,  though  it  is  all  right  for  the 
thin  man,  for  he  soon  learns  to  enjoy  his  food. 
But  the  stout  man  does  not  want  to  give  up  his 
butter,  and  keeps  on  eating  a  little  more  than 
he  needs.  Otherwise  it  would  be  as  easy  to 
reduce  as  to  fatten  an  individual.  You  can 
succeed  even  here  in  nine  cases  out  of  ten,  pro- 
vided all  the  instructions  are  rigidly  carried  out. 


LECTURE  V 
THE  CARE  OF  DIGESTION1 

Digestion  deals  with  the  processes  of  food 
ingestion,  assimilation,  and  ultimate  waste  elimi- 
nation. Health  and  life  are  dependent  upon  the 
harmonious  working  of  the  digestive  apparatus. 
Its  disturbed  function  creates  disease;  its  inter- 
ruption for  a  longer  time  carries  death  with  it. 

It  appears  worth  while  to  consider  here  some 
of  the  points  which  serve  to  keep  the  digestion 
in  good  shape,  in  order  thereby  to  preserve 
health. 

For  this  purpose  we  may  divide  our  subject 
matter  into  the  following  items:  (1)  Food 
intake:  quantity  required  in  growth,  manhood, 
old  age;  (2)  State  of  the  body  for  this  act;  (3) 
Period  of  assimilation;  (4)  The  final  act  of 
waste  elimination  (defecation). 

The  quantity  of  food  required  is  very  definite 

1  An  address  delivered  before  the  employees  of  New  York  City, 
October  11,  1916,  at  the  Municipal  Building,  New  York.  Medical 
Record,  Nov.  18,  1916. 

86 


THE  CARE  OF  DIGESTION  87 

and  is  greater  in  the  period  of  development  and 
manhood  than  in  middle  age  or  old  age.  During 
the  time  of  growth  a  large  quantity  of  the  nour- 
ishment is  utilized  for  the  upbuilding  of  the 
body.  In  manhood  the  greatest  activity  is 
manifested,  and  this  again  requires  additional 
nutritive  material.  In  middle  and  advanced 
age  the  activities  are  gradually  reduced  and  the 
food  requirements  are  accordingly  lessened. 
With  the  beginning  of  middle  age  there  is  often 
a  tendency  to  corpulence;  for  occasionally  at 
this  period  with  the  reduction  of  work  there  is 
no  decrease  in  the  quantity  of  food  intake.  The 
surplus  of  nutritive  material  is  then  stored  up 
in  the  body  in  the  form  of  fat. 

The  diet  should  be  watched  and  arranged 
somewhat  differently  for  these  different  periods 
of  life. 

In  most  instances  in  health  our  instinct  guides 
us  correctly  and  the  appetite  is  a  sufficient 
monitor  to  go  by.  Transgressions  may,  how- 
ever, occur  in  both  directions  by  faulty  habits 
(overeating  on  the  one  hand  and  too  scanty 
nutrition  on  the  other).  Thus  opulence  and 
high  living  give  rise  to  an  overabundance  of  the 
food  intake,  while  poverty  and  avarice  in  the 


88  LECTURES  ON  DIETETICS 

parent's  house  or  in  the  boarding  establishment 
may  lead  to  subnutrition.  Both  hypernutri- 
tion  and  subnutrition  practised  for  a  longer 
time  may  become  established  as  a  habit,  i.e. 
the  appetite  here  becomes  deranged  and  is  no 
more  a  fit  guide  for  the  best  purposes  of  the 
organism. 

In  order  to  look  for  good  health  we  must  guard 
against  either  of  these  faults. 

How  shall  we  know  whether  we  eat  just  right? 
The  quantity  of  food  physiolpgically  required  is 
known,  and  for  the  physician  it  is  a  simple  mat- 
ter to  make  a  computation  and  to  state  whether 
somebody  eats  enough,  too  much,  or  too  little. 

The  layman,  however,  can  likewise  easily  find 
the  right  measure.  First,  his  appetite  may  be 
used  as  a  guide;  second,  everybody  should  eat 
about  as  much  and  as  often  as  his  neighbors 
and  associates; third, everybody  can  see  whether 
his  body  and  strength  are  in  good  condition.  If 
everything  is  harmonious  and  goes  on  smoothly, 
this  alone  is  sufficient.  If  not  the  scale  may 
be  utilized  and  weighing  yourself  once  a  week  or 
so  will  soon  show  whether  there  be  too  much  or 
too  little  food  taken. 

What  kinds  of  foods  should  be  taken  ?     Here, 


THE  CARE  OF  DIGESTION  89 

again,  the  answer  is :  look  at  your  neighbors,  do 
the  same,  and  you  will  not  go  wrong. 

The  following  rules  may,  however,  be  given 
in  a  general  way.  Arrange  for  a  great  variety 
of  food,  which  should  embrace  most  nutritive 
substances  easily  digestible  and  also  difficult  of 
digestion.  To  select  a  diet  in  health  consisting 
merely  of  easily  assimilable  foods  would  be  a 
great  mistake  as  it  would  serve  to  decrease  the 
efficiency  of  our  digestive  apparatus. 

Eating  being  one  of  the  most  important  func- 
tions of  the  organism  should  not  be  done  hap- 
hazard, but  performed  with  care.  A  moderate 
amount  of  work  preceding  the  meal  increases  the 
appetite  and  enhances  the  digestive  function. 

A  few  more  rules  regarding  diet  in  health  may 
here  be  added.  There  is  a  tendency  in  this 
country  toward  eating  too  much  meat,  which 
often  leads  to  constitutional  disturbances.  Some 
people  here  take  meat  regularly  at  each  meal. 
As  a  rule  meat  should  be  partaken  of  once  or 
twice  daily  in  quantities  of  about  one-quarter 
of  a  pound  for  an  adult,  but  not  much  above 
this.  Plenty  of  vegetables  should  be  served 
with  it.  Bread  and  butter,  fruits,  and  salads 
should  be  used  liberally.  Water  should  be 


90  LECTURES  ON  DIETETICS 

taken  with  each  meal,  and  if  thirst  be  present 
also  in  between.  Its  importance  cannot  be 
too  much  appreciated. 

Water  itself  is  one  of  the  principal  ingredients 
of  the  organism.  It  contains,  besides,  in  small 
quantities,  mineral  salts  of  different  kinds  which 
are  utilized  in  the  body  economy.  Food  diges- 
tion, assimilation,  and  elimination  require  for 
^these  processes  water  as  an  intermediary,  without 
which  life  is  impossible.  Fresh  cool  spring 
water  at  meal  time  increases  the  appetite  and 
augments  the  pleasure  of  eating. 

Too  great  fatigue  destroys  the  appetite  and 
banishes  the  joy  of  eating.  The  latter  is  then 
done  mechanically,  almost  with  disgust,  and  the 
process  of  digestion  is  thus  disturbed  right  from 
the  start.  During  meal  time  rest  of  the  mind 
and  body  is  essential.  A  comfortable  seat,  a 
nicely  set  table,  pleasant  company,  wholesome 
food  and  drink  (fresh  spring  water)  are  impor- 
tant factors  in  increasing  the  worth  of  the  meal. 
General  conversation  not  requiring  much  con- 
centration of  mind  is  rather  useful.  Direct 
business  talk  should  be  avoided.  The  meal 
should  be  ingested  leisurely  and  time  given  to 
the  enjoyment  of  the  different  courses  (food 


THE  CARE  OF  DIGESTION  91 

articles).  The  eating  should  be  performed 
neither  too  quickly  nor  too  slowly.  Both  devia- 
tions lead  to  manifold  digestive  disturbances.  A 
short  period  of  rest  following  the  meal  is  advan- 
tageous. A  mild  cigar  and  pleasant  conversa- 
tion contribute  toward  the  enjoyment  of  this 
after-table  act. 

The  real  act  of  digestion  begins  after  the 
ingestion  of  food.  The  alimentary  canal  may 
be  likened  to  a  factory  in  which  all  the  material 
brought  in  is  sorted  and  changed  in  such  a  man- 
ner that  it  can  enter  the  circulation  and  by  means 
of  that  stream  of  communication  reach  all  the 
body  tissues. 

ASSIMILATION  OF  FOOD 

Unfit  substances  or  the  remnants  of  food 
which  cannot  be  utilized  any  more  are  carried 
along  the  digestive  canal  to  be  eliminated  at  the 
end.  The  tissues  of  the  body  likewise  throw 
off  dead  or  waste  material.  They  accomplish 
this  through  the  eliminative  systems  (lungs, 
kidneys,  skin,  and  alimentary  tract,  including 
the  liver)  reached  by  all  the  tissues  through  the 
blood  stream.  The  digestive  canal  is  thus  one 
of  the  principal  avenues  for  the  traffic  also  of 
waste  products  of  the  body  itself. 


92  LECTURES  ON  DIETETICS 

The  assimilation  is  greatly  favored  by  keeping 
the  body  in  good  trim.  For  this  the  organism 
must  be  in  a  state  of  contentment,  which  can 
be  reached  by  satisfactory  mental  and  bodily 
work.  Every  occupation  should  be  performed 
with  a  good  will  and  pleasure,  and  should  not  be 
carried  on  to  over-fatigue  and  annoyance.  Thus 
assimilation  will  be  helped  and  good  health 
made  possible.  Plenty  of  fresh  air  and  a  certain 
amount  of  muscular  exercise  (walking,  horseback 
riding,  rowing,  gymnastics)  are  of  importance. 
In  the  same  way  after- the  working  hours  rest  and 
a  sufficient  amount  of  sleep  (eight  hours  daily) 
are  essential  for  good  digestion  and  perfect  health. 
Both  exercise  and  rest,  properly  apportioned, 
enhance  assimilation  as  well  as  elimination. 

The  final  act  of  digestion  consists  in  the  expul- 
sion of  all  the  remaining  unutilizable  food  sub- 
stances and  some  waste  products  from  the 
alimentary  tract  (defecation) .  This  usually  oc- 
curs once  daily  in  normal  individuals.  Regular 
attendance  to  this  natural  event  is  likewise 
important  for  the  well-being  of  the  organism. 
With  regard  to  this  act  the  call  of  nature  should 
be  obeyed  at  the  right  time.  Frequent  neglect 
to  perform  this  duty  as  well  as  too  much  devo- 


THE  CARE  OF  DIGESTION  93 

tion  to  it  lead  to  irregularities  of  the  bowel  and 
ultimately  to  ill  health.  In  health  the  best 
principle  is  to  let  things  take  their  natural  course. 
Too  much  interference  with  it  often  leads  to 
abnormal  conditions  and  disease. 

To  sum  up,  the  care  of  good  digestion  embraces 
the  following  items:  simple  life,  in  which  work 
and  rest  for  mind  and  body  are  harmoniously 
divided;  regularity  of  meals,  frugality,  great 
diversity  of  wholesome  foods  taken,  in  just  the 
right  proportion;  an  abundance  of  water;  proper 
attention  to  the  call  of  nature.  Good  digestion 
is  also  the  best  promoter  of  good  health  and 
a  long  life.  There  is  no  elixir  of  youth  for  old 
age,  or  a  rejuvenation  remedy.  In  keeping  our 
organism,  however,  in  good  trim,  in  looking  out 
for  its  steady  and  harmonious  activity,  we  suc- 
ceed in  delaying  and  perhaps  also  shortening 
the  advancing  state  of  invalidism  and  the  dissolu- 
tion period,  with  death  at  its  end. 

Life  is  not  complete  without  death.  The 
latter  is  a  natural  event  at  some  time  for  each 
living  being  and  its  advent  should  not  be 
begrudged. 


LECTURE  VI 
THE  CARE  OF  DIGESTION  FOR  THE  SOLDIER1 

Digestion  deals  with  the  food  intake  and  its 
complete  assimilation.  The  aim  of  the  soldier 
is  efficiency  and  a  capacity  for  strenuous  work, 
without  injury  to  the  system.  In  order  to 
accomplish  this,  greater  amounts  of  food  than 
normal  must  be  taken.  The  demands  made  on 
the  soldier's  digestion  will  be  correspondingly 
greater. 

The  usual  principles  for  the  care  of  digestion 
can  be  briefly  summarized  as  follows :  Regularity 
in  taking  meals,  eating  leisurely,  diversity  of  foods, 
frugality,  work  and  rest  proportionately  divided. 
Neither  overfatigue  nor  too  much  leisure  should 
be  allowed  to  occur. 

Although  these  maxims  pertain  to  all  individ- 
uals alike,  the  soldier  included,  and  should  be 
followed,  whenever  feasible,  the  army -man  is  so 
placed  that  he  frequently  cannot  obey  these  laws. 

For  this   reason  it   appears    appropriate    to 

1  Written  during  my  service  period  at  Camp  Upton.  Medica 
Record,  February  9th,  1918. 

94 


THE  CARE  OP  DIGESTION  95 

consider  how  best  to  act  in  these  precarious 
conditions  of  a  soldier's  life. 

1.  The  Food  Problem. — A  greater  diversity  of 
foods  is  usually  impossible  in  camp  life.  The 
soldier  will  therefore  do  well  to  partake  of  every 
article  of  food  offered  him  in  order  to  avoid  a  diet 
that  would  be  too  one-sided. 

As  a  rule  he  should  endeavor  to  partake  of  the 
entire  portion  of  cereals,  vegetables  and  fruits 
allotted  to  him  and  of  meat  as  much  as  he  desires. 
Peas,  beans  and  lentils  contain  a  considerable 
quantity  of  protein  and  should  be  indulged  in 
liberally.  Fruit-jellies  and  jams  are  useful  when 
fresh  fruit  cannot  be  had.  The  foods  usually 
being  concentrated,  it  is  important  to  have  tea, 
coffee,  or  cocoa,  with  milk  and  sugar  at  each 
meal,  also  good  drinking  water.  The  latter 
should  be  taken,  one  to  two  glassfuls  (according 
to  the  requirements  of  the  body;  more  in  hot 
weather  than  in  cold)  at  each  meal. 

2.  Rules  for  Meals.  — (a)  When  activity  is 
known;  (6)  For  exceptional  and  undeterminable 
work. 

(a)  The  soldier  should  lead  as  regular  a  life  as 
is  compatible  with  his  duties.  Meals  should  be 
taken  at  regular  intervals,  if  possible,  at  about 


96  LECTURES  ON  DIETETICS 

the  same  time  every  day.  Some  time  should  be 
spent  in  consuming  a  meal,  eating  leisurely, 
neither  too  fast  nor  too  slowly.  The  morning 
meal  should  be  the  lightest  of  the  three  meals. 
A  short  period  of  rest  (spent  in  conversation, 
smoking,  etc.)  after  meals  is  advisable.  After 
the  evening  meal,  this  period  of  leisure  should  be 
extended  over  a  longer  time.  Anything  that 
contributes  to  the  amusement  of  the  individual 
will  be  of  help  toward  a  healthy  digestion. 
Playing  of  games  or  listening  to  music  and  story 
telling,  is  therefore,  highly  commendable. 

(6)  When  there  is  a  hurry  call  and  the  meal- 
time must  be  considerably  shortened,  the  soldier 
will  do  well  to  partake  of  a  rather  small  quantity 
of  light  foods.  A  cup  of  warm  (not  hot)  coffee  or 
tea  and  bread  and  butter  or  a  sandwich,  or  por- 
ridge will  best  serve  the  purpose.  Hot  dishes 
and  meats  are  not  appropriate  at  such  hurried 
occasions.  The  reason  why  larger  meals  and 
heavy  foods  are  here  not  desirable  is  because  the 
soldier  then  has  no  time,  nor  the  desire  to  masti- 
cate the  food  properly.  A  heavy  meal  faultily 
ingested  may  easily  lead  to  bad  consequences. 

Similarly,  a  meal  which  must  be  taken  after 
exhausting  marches  or  other  overstrenuous  work 


THE  CARE  OP  DIGESTION  97 

or  after  prolonged  fasting,  should  be  of  a  light 
character  and  of  a  rather  moderate  quantity. 
After  a  period  of  rest,  the  next  meal  may  be 
taken  in  full  amount  and  in  the  usual  manner. 

3.  Urination. — Passing    of    urine    should    be 
done  at  regular  intervals,  if  feasible.     Empty  the 
bladder  when  arising  and  retiring,  also  before 
starting  out  for  a  prolonged  march   or   other 
important  steady  work. 

4.  Defecation. — Attempt  to  have  a  movement 
of  the  bowels  when   arising.     If  unsuccessful, 
do  not  worry  about  it,  nor  think  of  it.     When- 
ever   there    is    an    inclination    for    defecation, 
nature's  call  should  be  obeyed;  otherwise,  wait 
until   the   next   morning.     Drinking   of   water, 
ingesting  larger  amounts  of  fruits,  salads,  jams 
and  vegetables  will  greatly  contribute  toward  a 
regularity  of  the  bowel  movement. 

5.  Rest. — The    soldier    being    subjected    to 
strenuous  work  must  also  have  periods  of  rest. 
This  applies  here  in  a  still  higher  degree  than  in 
ordinary   life.     Efficiency   is  impossible  unless 
there  is  complete  recreation  after  fatigue. 

6.  Sleep. — Sleep  is  the  acme  of  rest.     In  this 
state  the  muscles,  nerves  and  brain  cells  are 
completely  relaxed,  and  the  blood  stream  washes 


98  LECTURES  ON  DIETETICS 

out  and  carries  away  all  waste  products  which 
had  accumulated  during  the  period  of  work. 
Eight  hours'  sleep  should  be  allotted,  unless  in 
exceptional  straits,  when  this  period  may  be 
somewhat  shortened. 

Rest  and  sleep  are  essential  factors  in  keeping 
the  digestion  in  good  trim.  For  this  reason  as 
much  attention  should  be  paid  to  these  two 
factors  as  to  the  other  items  regarding  nutrition. 

At  first  glance  it  appears  rather  impossible 
for  a  soldier  to  take  good  care  of  his  digestive 
apparatus.  For  many  of  the  conditions  pre- 
vailing in  army-life  are  necessarily  contrary  to 
hygiene.  In  reality,  however,  the  soldier  quickly 
accommodates  himself  to  the  new  conditions, 
and  his  digestion  is  as  good  as  in  civil  life.  It 
is  a  great  blessing  of  nature  to  have  fitted  our 
organism  with  a  great  deal  of  elasticity,  so  that 
it  can  adapt  itself  to  the  most  unfavorable  states. 

In  observing  the  rules  outlined,  good  digestion 
will  be  considerably  enhanced  in  the  soldier. 


LECTURE  VII 

THE  DIETETIC  TREATMENT  OF  CHRONIC 
DIARRHEAS1 

I  have  selected  the  dietetic  treatment  of 
chronic  diarrhea  because  this  subject  of  diet  is  an 
important  one  in  all  diseases,  and  particularly  so 
in  affections  of  the  digestive  tract,  as  there  we 
have  to  deal  with  an  apparatus  which  is  arranged 
to  sustain  the  organism. 

In  order  to  discuss  this  subject  of  dietetic 
management  of  chronic  diarrhea,  it  would  be 
well  to  divide  its  forms  into  different  classes. 

1,  Diarrhea  due  to  chronic  intestinal  obstruction; 

2,  nervous  diarrhea;  and  3,  chronic  diarrhea,  due 
to   catarrh   of  the   small  intestine  principally, 
sometimes    also    accompanied    by    a  catarrhal 
condition  of  the  colon.     Most  forms  of  chronic 
diarrhea   mainly   involve   the   small  intestine; 
and  this  group  can  again  be  subdivided  into  1, 
primary    catarrh;    2,    catarrh   depending  upon 
abnormalities  of  gastric  secretion;  and  3,  catarrh 
accompanying  ulceration. 

1  New  York  Med.  Journal,  Feb.  10,  1906. 
99 


100  LECTURES  ON  DIETETICS 

In  the  treatment  of  all  these  types  of  diarrhea 
it  is  primarily  important  that  we  should  make  use 
of  those  foods  which  are  nonirritating  and  which 
leave  little  residue.  They  must  not  irritate  the 
bowel  mechanically  or  chemically,  nor  must  they 
be  very  cold  when  ingested. 

The  special  treatment  of  each  class  will  call 
for  a  variation  in  the  dietetic  regime.  In  chronic 
intestinal  obstruction,  so  long  as  the  patient  is 
not  operated  on  and  the  obstruction  exists,  the 
first  principle  will  be  that  the  diet  should  be  a 
liquid  one.  This  liquid  diet  will  have  to  be 
maintained  because  solid  food  will  not  pass 
through  the  narrowed  canal.  It  will  be  vomited 
and  will  aggravate  the  symptoms.  We  may 
give  milk,  raw  eggs,  and  different  kinds  of  broths 
and  meat  juices,  but  this  will  be  all  which  we  may 
allow.  Variations  to  improve  the  taste,  and 
bring  more  variety  into  the  menu  may  be  intro- 
duced, but  in  the  main  the  foods  will  remain  the 
same. 

A  reverse  course  must  be  adopted  in  that  form 
of  diarrhea  which  is  of  nervous  origin.  In  this 
disorder,  as  far  as  we  know,  there  is  really  no 
anatomical  lesion  to  be  found.  It  is  simply  a 
functional  disease,  and  the  chief  feature  of  this 


TREATMENT  OF  CHRONIC  DIARRHEAS    101 

type  of  diarrhea  is  that  nervous  phenomena 
accompany  it  and  also  bring  it  on.  This  means 
that  in  addition  to  a  diarrhea  the  patient  also 
manifests  other  nervous  symptoms .  He  perhaps 
cannot  sleep  well,  his  appetite  is  capricious,  and 
then  the  diarrhea  itself  also  manifests  a  character 
which  shows  its  nervous  origin.  The  patient 
will  have  a  movement  of  the  bowels  principally 
after  meals,  or  when  he  will  have  to  meet  a 
very  important  engagement;  a  professor  before 
giving  a  lecture  will  have  to  excuse  himself  and 
leave  the  room,  indicating  that  the  state  of  mind 
has  something  to  do  with  the  movement  of  the 
bowels. 

In  these  cases  the  whole  management  should 
be  different  from  those  which  are  due  to  anatomi- 
cal lesions  in  the  intestines.  The  diet,  too,  must 
therefore  be  arranged  accordingly.  It  will  not 
have  to  be  such  a  rigorous  one.  We  will  have 
to  make  the  patient  eat  almost  everything. 
Even  those  foods  which  leave  a  residue  do  not 
play  much  part.  I  remember  I  had  to  treat  a 
physician  in  this  city  who  had  this  kind  of  a 
diarrhea.  He  had  to  excuse  himself  after  finish- 
ing each  meal.  The  main  treatment  is  that  the 
patient  should  try  and  suppress  these  move- 


102  LECTURES  ON  DIETETICS 

ments,  i.  e.,  not  to  run  to  the  toilet  as  often  as  he 
feels  inclined,  and  besides  other  means,  nerve 
sedatives.  The  diet  should  not  be  restricted; 
food  of  a  laxative  nature,  however,  should  be 
avoided;  otherwise  these  patients  can  eat 
everything. 

Now  we  come  to  that  class  of  diarrhea  which 
is  due  to  disturbances  of  the  stomach.  This  is  a 
group  which  has  been  recognized  only  in  the  last 
twenty  years.  We  have  learned  to  know  that 
there  are  forms  of  diarrhea  in  which  the  small 
and  large  intestines  are  not  very  much  involved, 
but  in  which  we  find  abnormal  conditions  in 
the  stomach  itself,  and  if  we  try  to  arrange  a 
treatment  suitable  to  the  derangement  of  the 
stomach,  the  diarrhea  as  such  can  be  disregarded 
and  still  will  be  cured. 

There  are  two  lesions  in  the  stomach,  func- 
tional disturbances,  which  form  the  greater  part 
of  this  class  of  diarrheas.  One  is  the  form  which 
is  called  achylia  gastrica,  in  which  there  is  no 
gastric  juice  whereby  the  stomach  does  not  digest 
albuminoid  foods.  Here  the  food  enters  the 
intestine  practically  unchanged,  and  thus  irri- 
tates the  bowel,  causing  the  diarrhea,  at  least 
in  some  cases.  Achylia  gastrica  is  not  always 


TREATMENT  OF  CHRONIC  DIARRHEAS   103 

accompanied  by  diarrhea.  I  think,  on  the  con- 
trary, that  more  than  one  half  of  the  cases 
are  accompanied  with  extreme  constipation,  but 
about  one  third  of  these  cases  of  achylia  gastrica 
are  troubled  with  obstinate  diarrhea,  and  this 
diarrhea  is  probably  due  to  mechanical  irritation 
within  the  small  intestine. 

Diarrhea  may  also  be  brought  on  by  just  the 
reverse  condition,  i.  e.,  one  in  which  there  is  too 
much  secretion  and  too  much  acidity  in  the 
stomach.  Here  it  is  not  the  mechanical  irrita- 
tion but  most  likely  the  acid  itself  which  exerts 
an  irritating  stimulus  on  the  intestinal  mucosa, 
which  leads  to  the  diarrhea .  This  class ,  however, 
is  a  small  one.  Most  patients  who  suffer  from 
hyperchlorhydria  are  afflicted  with  constipation, 
and  only  a  small  fraction  suffer  from  diarrhea, 
but  we  must  remember  that  such  a  group  exists, 
as  sometimes  they  may  be  cured  by  alkalies. 

In  these  two  groups,  in  which  the  diarrhea  is 
dependent  upon  a  gastric  anomaly,  the  entire 
treatment,  medicinal  and  dietetic,  will  have  to 
be  arranged  to  suit  the  stomach.  In  the 
patients  with  achylia  gastrica  we  find  it  expedi- 
ent empirically,  not  merely  theoretically,  to 
exclude  proteids  from  the  diet.  Such  patients 


104  LECTURES  ON  DIETETICS 

do  much  better  on  a  diet  which  contains  little 
meat  or  no  meat  at  all.  They  should  live  on  a 
vegetarian  diet.  A  vegetable  diet  is  inclined,  as  a 
rule,  to  predispose  to  diarrhea,  but  in  this  group 
of  cases  it  is  just  the  remedy.  If  one  keeps  a 
patient  on  gruels  and  perhaps  on  nicely  divided 
articles  of  food,  milk,  kumyss,  later  on  bread 
and  butter  and  omits  meat  entirely  for  a  time, 
one  will  find  that  in  a  few  weeks  he  will  not  suffer 
so  much  from  the  diarrhea.  I  think  this  to  be 
the  experience  of  almost  all  the  physicians  who 
handle  these  cases.  According  to  my  experience, 
however,  it  is  not  necessary  to  institute  a  rigor- 
ous diet  nor  to  avoid  meats  altogether  for  a  very 
long  period.  If  we  give  the  patient  finely 
divided  foods  for  a  few  weeks,  at  first  liquid,  then 
semi-liquid  foods,  we  can  then  after  a  time 
begin  to  allow  foods  a  little  coarser,  bread, 
vermicelli,  barley,  rice,  and  later  on  meat.  We 
will  find  that  the  bowels  will  gradually  get 
accustomed  to  these  foods,  even  if  the  latter  do 
not  get  into  the  intestine  in  so  finely  divided  a 
state.  These  patients  should  masticate  their 
food  carefully.  This  is  more  important  here 
than  in  any  other  class  of  stomach  derangements. 
These  patients  do  well  on  starchy  foods. 


TREATMENT  OF  CHRONIC  DIARRHEAS   105 

Diarrhea,  if  due  to  a  condition  of  hyperchlor- 
hydria,  will  have  to  be  managed  quite  differently. 
Here  meats,  a  richly  albuminous  diet,  will  play 
an  important  part.  These  patients  will  do  well 
on  plenty  of  meat  and  eggs,  and  very  little 
starchy  food — just  the  opposite  of  those  suffering 
from  achylia — and  also  an  alkali. 

In  the  first  group,  achylia  gastrica,  it  is  not 
essential  to  administer  hydrochloric  acid,  but 
in  the  second  group,  hyperchlorhydria,  we  will 
have  to  give  alkalies. 

We  shall  proceed  now  to  the  larger  group  of 
chronic  diarrhea,  due  to  abnormal  conditions  in 
the  small  intestine.  This  is  the  more  difficult 
group  to  handle  outside  of  the  group  due  to 
intestinal  obstruction  (which  we  can  only  cure 
by  an  operation;  otherwise  we  have  to  keep  to 
liquid  diet).  This  group,  in  which  there  is  a 
chronic  catarrh  of  the  small  intestine,  comprises 
perhaps  more  than  half  the  cases  suffering  from 
diarrhea.  Here  diet  plays  a  very  important 
part,  and  we  will  have  to  discuss  a  little  more 
minutely  how  to  handle  them  and  what  we  should 
do. 

There  is  no  unanimity  of  opinion  among 
physicians  nowadays  as  to  the  kind  of  diet  to 


106  LECTURES  ON  DIETETICS 

be  given  to  such  patients.  Some  say  that  these 
patients  will  do  well  on  an  exclusive  meat  diet; 
others  again  will  say  that  patients  get  well  on  a 
strict  milk  diet.  Others  again  say  that  milk  is 
the  worst  thing.  Among  the  latter  is  Professor 
Rosenheim,  who  recently  wrote  an  article  on 
this  group  of  diarrheas.  He  says  that  he  always 
failed  with  milk  in  such  cases,  because  the  milk 
sugar  easily  breaks  down  into  lactic  acid,  which 
upsets  the  patient.  He  therefore  excludes  milk 
from  the  diet  of  these  patients.  He  even  goes 
so  far  as  saying  that  the  admixture  of  milk  to 
cacao  or  to  soup,  and  a  little  cream  will  also 
upset  the  patient. 

So  far  as  I  am  concerned  I  must  say  that  I  am 
not  so  much  afraid  of  milk  and  I  am  rather  of 
the  opinion  that  while  we  should  exclude  all 
fruits,  salads,  highly  spiced  dishes,  all  irritating 
substances  and  cold  beverages  (all  things  which 
have  a  tendency  to  increase  peristalsis  should 
be'carefully  avoided),  we  should  still  try  to  give 
a  sufficient  quantity  of  nourishment  to  these 
patients  even  if  their  actual  condition  of  diarrhea 
should  apparently  grow  worse  through  the  diet. 
I  am  of  the  opinion  that  if  we  are  timid  and  give 
these  patients  very  little  food,  they  will,  not- 


TREATMENT  OF  CHRONIC  DIARRHEAS   107 

withstanding  the  improvement  of  their  diarrhea, 
perhaps  having  only  two  or  three  movements 
a  day,  soon  suffer  in  their  nutrition  and  the  body 
weight  will  decrease.  The  great  danger  is  that 
if  such  a  condition  of  subnutrition  is  kept  up, 
after  a  while  we  cannot  cure  such  patients  at  all. 
This  is  the  case  with  a  great  many  of  these 
patients. 

In  reality  it  is  advisable  to  give  rest  to  an 
organ  which  is  diseased  and  it  will  then  recuper- 
ate and  do  well  later  on  and  do  more  work. 
You  may,  in  severe  cases  of  diarrhea,  try  such 
treatment.  We  may  give  the  patient  very  little 
nourishment,  perhaps  egg  albumen  water,  but 
if  so  one  should  always  bear  in  mind  not  to 
restrict  the  patient  to  this  diet  for  more  than  a 
week  or  ten  days.  After  this  period  we  must 
reestablish  the  amount  of  nourishment,  and 
put  the  patient  on  a  regime  which  will  build  him 
up.  It  is  important  to  consider  that  even 
though  the  patient  feels  improved  and  the 
chronic  diarrhea  gets  better  on  the  restricted 
diet,  he  may  be  getting  too  little  nutrition  and  a 
state  of  inanition  results.  The  organs  are  weak- 
ened and  the  disease  instead  of  growing  better 
becomes  aggravated.  In  this  weakened  state 


108  LECTURES  ON  DIETETICS 

the  organism  is  not  able  to  recuperate.  For  this 
reason  I  say  that  in  these  cases  of  chronic 
diarrheas,  after  having  tried  a  very  short  period 
of  time  with  little  nutrition  or  no  nutrition  at  all, 
we  must  give  them  plenty  of  food,  plenty  of 
eggs — eggs  are  indeed  very  good  in  these  cases 
—six  or  eight  eggs  a  day  I  generally  give.  We 
give  them  plenty  of  gruels  and  barley.  You  may 
try  decoctions  of  barley,  oatmeal  and  rice,  and 
later  on  give  them  porridges,  and  then  bread  and 
butter,  and  then  meats.  I  do  not  exclude  meats. 
I  do  not  give  them  any  fruits,  salads  or  any  cold 
drinks  or  anything  of  an  irritating  nature. 
Nourish  them  well. 

What  will  you  do  if  the  diarrhea  is  kept  up? 
How  will  you  manage  that?  Here  certainly  we 
must  take  recourse  to  some  medicinal  treatment. 
We  may  give  them  a  tannic  acid  preparation, 
tannin-agar;  we  may  administer  an  opiate.  It 
is  much  better  to  make  the  patients  eat  and 
keep  them  on  some  remedy,  so  that  they  are 
able  to  keep  up  with  feeding  and  check  the 
diarrhea  a  little,  than  not  to  allow  them  to  eat 
and  not  to  take  medicine. 

I  have  found  by  experience  that  a  great  many 
patients  soon  begin  to  gain  in  weight,  in  fact  in 


TREATMENT  OF  CHRONIC  DIARRHEAS    109 

most  of  these  cases  you  can  achieve  a  gain  in 
weight  if  you  give  them  sufficient  nourishment, 
more  than  enough  to  keep  the  body  in  balance. 
They  will  add  flesh  too,  and  as  soon  as  they  are 
stronger  they  are  able  to  fight  the  disease  and  do 
not  require  so  much  medicine.  I  have  seen  such 
cases.  I  particularly  remember  a  patient  who 
lost  fifty  to  sixty  pounds  from  chronic  diarrhea. 
She  did  not  eat  anything  that  was  forbidden  her, 
and  she  thought  that  milk  increased  the  diarrhea, 
also  bread,  and  she  did  not  wish  to  eat.  Ulti- 
mately she  took  nothing.  Her  condition  was  so 
bad  that  she  was  almost  a  skeleton,  but  after  I 
allowed  her  to  eat  and  gave  her  in  addition  some 
slight  remedy,  after  a  few  weeks  she  picked  up 
and  in  two  or  three  months  recovered. 

It  is  thus  with  a  great  many  other  patients, 
and  I  think  it  is  very  essential  to  bear  in  mind 
how  important  a  part  nutrition  plays  in  pro- 
longing life  and  curing  disease. 


LECTURE  VIII 

THE  DIETETIC  TREATMENT  OF  DIABETES 
MELLITUS1 

In  no  disease  does  diet  form  a  more  impor- 
tant part  of  the  treatment  than  in  diabetes 
nielli tus.  As  is  well  known,  the  nature  of  the 
disease  consists  in  the  fact  that  the  organism  is 
unable  either  entirely  or  nearly  so  to  utilize 
the  carbohydrate  foods.  We  thus  have  to  deal 
with  a  genuine  anomaly  of  metabolism,  and  the 
main  points  of  treatment  will  consist  of  a  rational 
and  appropriate  diet  so  long  as  there  is  no  specific 
remedy  for  this  disease. 

As  it  is  possible  to  live  on  meat  and  fat  alone 
without  carbohydrates,  it  was  natural  to  exclude 
this  latter  group  of  food-stuff  from  the  diabetic 
diet.  This  was,  indeed,  done  by  the  earliest 
observers  who  had  knowledge  of  the  nature  of 
diabetes  (Rollo,  1796),  and  this  diet  was  adhered 

1  Remark:  This  lecture  is  left  as  delivered  in  1906.  It  is  applicable 
even  now  especially  in  cases  not  suitable  for  the  Allen  treatment. 
The  only  restriction  will  apply  to  the  amount  of  fats  given. 

1  Journal  American  Medical  Association,  Dec.  29,  1906. 

110 


TREATMENT  OF  DIABETES  MELLITUS  111 

to  with  slight  modifications  until  the  present 
time. 

The  following  disadvantages  are  attached  to 
a  purely  animal  diet :  It  offers  too  little  variety 
and  departs  too  much  from  the  usual  mode  of 
life,  and  in  this  way  will  soon  pall  on  the  appetite. 
At  the  same  time  it  is  poor  in  inorganic  salts, 
thus  predisposing  to  a  surcharge  of  the  organism 
with  acids  (acidosis)  and  subsequent  comatose 
conditions. 

An  absolute  meat  and  fat  diet  can  be  borne 
for  only  a  short  period.  Such  a  diet  would  be 
about  as  follows : 

STRICT    DIET 

8  A.  M.:  Two  eggs,  butter,  tea;  11  A.  M.:  Ham, 
wine;  1  p.  M.  :  Beef  tea,  200  grams  of  meat  or  fish,  one 
egg,  lettuce  or  spinach;  4  p.  M.:  Coffee,  two  eggs  and 
butter;  7  P.M.:  Three  eggs  fried  in  lard,  or  fish  with  eggs 
or  cold  roast. 

A  trace  of  sugar  is  contained  even  in  this  diet, 
but  it  hardly  amounts  to  over  1  per  cent.  By 
the  addition  of  some  milk  and  cream  this  diet 
may  be  made  a  little  more  agreeable,  although 
the  quantity  of  sugar  is  greater. 

Such  a  diet  list  may  be  put  together  about  as 
follows : 


112  LECTURES  ON  DIETETICS 

INTERMEDIATE    DIET 

Breakfast:  200  grams  of  milk  with  50  grams  of  cream, 
two  eggs,  butter  and  100  grams  of  roast. 

Dinner:  200  grams  of  meat  or  fish  with  asparagus  or 
peas,  salads. 

4  p.  M.:  200  grams  of  milk  with  50  grams  of  cream. 
Supper:  Four  scrambled  eggs  with  120  grams  of  ham. 

C.  von  Noorden1  determines  first  how  much 
carbohydrate  a  patient  can  assimilate  and  allows 
about  half  of  this.  Such  a  procedure  appears 
very  rational,  but  can  be  conducted  only  in 
special  clinics  and  not  in  general  practice.  It 
is  best  to  arrange  the  diet  according  to  customary 
principles,  varying  it  slightly  to  fit  the  individual 
requirements  of  the  patient.  Whether  or  not  a 
diet  agrees  with  the  patient  can  best  be  deter- 
mined by  noting  the  diminution  of  the  quantity 
of  sugar,  as  well  as  the  total  daily  quantity  of 
urine,  and  secondly  and  mainly  by  the  patient 
feeling  better  and  stronger. 

According  to  the  experience  of  most  clinicians, 
it  is  best  to  permit  diabetics  a  certain,  although 
limited  amount  of  carbohydrates. 

Seegen's2  diet  list  for  diabetics  is  probably 

1 C.  von  Noorden:  "Ueber  Hafercuren  bei  schwerem  Diabetes 
mellitus,"  Berl.  klin.  Wochschr.,  1903,  No.  36,  p.  817. 

1 J.  Seegen:  "Der  Diabetes  mellitus,"  Berlin,  1895;  see  also  Frieden- 
wald  and  Ruhrah:  "Diet  in  Health  and  Disease,"  1905,  pp.  470-471. 


TREATMENT  OF  DIABETES  MELLITUS  113 

the  best  known  and,  therefore,  I  will  quote  it  in 
full: 

SOLIDS 

Allowed  in  Any  Quantity. — Meat  of  every  kind,  smoked 
meat,  ham,  tongue,  fish  of  every  kind,  oysters,  mussels, 
crabs,  lobsters,  meat  jellies,  aspic,  eggs,  caviar,  cream, 
butter,  cheese  and  bacon.  Of  vegetables:  Spinach, 
lettuce,  endive,  Brussels  sprouts,  pickles,  fresh  asparagus, 
watercress,  sorrell,  artichokes,  mushrooms,  nuts. 

Allowed  in  Moderate  Quantity. — Cauliflower,  carrots, 
turnips,  cabbage,  green  beans,  berries,  such  as  straw- 
berries, raspberries,  currants,  also  oranges  and  almonds. 

Forbidden  Absolutely. — All  foods  made  from  flour  or 
meal;  bread  is  allowed  in  moderate  quantities,  according 
to  the  physician's  orders;  sweet  potatoes,  rice,  tapioca, 
arrowroot,  sago,  grits,  vegetables,  green  peas,  cabbage, 
sweet  fruits,  especially  grapes,  cherries,  peaches,  apricots, 
plums  and  dried  fruit  of  every  sort. 

BEVERAGES 

Allowed  in  Any  Quantity. — Water,  soda  water,  tea  and 
coffee.  Of  wines :  Bordeaux,  Rhine  wine,  Moselle,  Aus- 
trian and  Hungarian  table  wines — in  a  word,  all  wines 
that  are  not  sweet  and  that  do  not  contain  more  than 
the  average  amount  of  alcohol. 

Allowed  in  Moderate  Quantity. — Milk,  bitter  beer, 
unsweetened  almond  milk,  lemonade  without  sugar. 

Forbidden. — Champagne,  sweet  beer,  cider,  fruit  wine, 
sweet  lemonade,  liqueurs,  fruit  juices,  water  ices,  sorbets, 
cocoa  and  chocolate. 

8 


114 


LECTURES  ON  DIETETICS 


In  general,  I  use  about  the  same  diet  as  Seegen 

and  give  the  following: 

Calories 

Breakfast:  Three  eggs 240 

Half  a  roll  (20  grams) 50 

Butter  (30  grams) 251 

Coffee  (150  grams),  milk  (100  grams), 

cream  (50  grams) 203 

Dinner:       A  plate  of  soup  (200  grams),  with  egg. .  85 

Meat  (200  grams) 200 

Hah*  a  roll  and  butter  (15  grams) 175 

Asparagus  with  butter  sauce  (salad) ...  30 

Supper:       Oysters  or  fish  (100  grams) 100 

Three    scrambled    eggs    with    butter 

(15  grams) 365 

Half  a  roll  with  butter  (15  grams) 175 

Westphalian  ham  (50  grams) 200 

Apples,  tea  and  cream  (50  grams) 138 


2,212 

Various  diet  cures  have  proved  of  value  in 
diabetes.  Of  these  the  best  known  are  the 
"milk  cure"  of  Winternitz,1  the  "potato  cure" 
of  Mosse",  and  the  "oatmeal  cure"  of  von 
Noorden. 2 

1  Winternitz  und  Strasser:  "Strenge  Milcbkuren  bei  Diabetes 
mellitus,"  Centbl.  f.  innere  Med.,  1890,  No.  45. 

•C.  von  Noorden:  "Ueber  Hafercuren  bei  schwerem  Diabetes 
mellitus/'  Berl.  klin.  Wochschr.,  1903,  No.  36,  p.  817. 


TREATMENT  OF  DIABETES  MELLITUS  115 

Whereas  Mosse's  potato  cure  has  not  proved 
of  much  value,  the  other  two  cures  are  useful 
in  suitable  cases.  They  should  not  be  extended 
over  too  long  a  time  because  a  too  limited  diet  is 
harmful  if  continued  too  long.  Winternitz's 
milk  cure  consists  in  the  patient  taking  milk 
exclusively  (about  four  quarts  daily). 

Von  Noorden  recommends  his  oatmeal  cure, 
especially  in  grave  cases  of  diabetes.  He  uses 
either  Knorr's  oatmeal  or  Hohenlohe's  oatmeal 
flakes.  This  substance  is  boiled  in  water  for 
a  long  time  with  a  little  salt;  while  boiling  butter 
and  a  vegetable  albuminoid  or,  after  cooling, 
the  beaten  white  of  eggs  are  added.  Roborant 
may  be  employed  for  this  purpose  with  good 
advantage.  The  daily  quantity  is  250  grams  of 
oatmeal,  100  grams  of  albumin  and  300  grams  of 
butter.  The  soup  prepared  in  this  manner  is 
given  every  two  hours.  Cognac  or  wine  or  black 
coffee  may  also  be  permitted. 

No  matter  what  form  of  diet  is  instituted,  it 
is  always  essential  to  see  that  the  quantity  of 
food  is  sufficient.  In  this  respect  fat  (butter, 
cream,  oil,  lard)  is  of  more  importance  here  than 
in  other  conditions.  Alcohol,  taken  moderately 
in  the  shape  of  whisky,  cognac  or  wine,  is  also 


116  LECTURES  ON  DIETETICS 

of  value.  The  body  receives  in  the  first  place 
more  fuel  (as  50  grams  of  alcohol,  which  may  be 
put  down  as  the  daily  quantity,  contain  about 
350  calories),  and  secondly  because  the  patient, 
with  the  addition  of  wine,  can  take  more  of  the 
greasy  food  than  without  it. 

STOMACH  COMPLICATIONS 

After  thus  having  touched  on  the  fundamental 
principles  of  diet  in  diabetes  mellitus,  I  would 
like  to  add  a  few  words  about  it  in  those  cases  of 
diabetes  which  are  complicated  with  affections  of 
the  stomach.  Two  groups  of  functional  disturb- 
ances of  the  stomach  are  found  most  frequently 
in  diabetes,  hyperchlorhydria  and  achylia. 

If  hyperchlorhydria  complicates  diabetes  the 
treatment  is  easy,  as  the  diet  is  the  same  in  both 
(principally  fat  and  albumin).  Even  the  medi- 
cinal treatment  of  hyperchlorhydria  (alkalies, 
sedatives)  influences  also  the  diabetes  favorably. 

It  is  different  in  achylia  gastrica  complicating 
diabetes.  As  is  well  known,  meat  is  not  well 
borne  in  achylia  gastrica,  whereas  a  vegetarian 
diet  (plenty  of  carbohydrate)  usually  agrees 
best  with  these  patients.  We  are  thus  con- 
fronted by  a  dilemma.  The  diabetes  requires 


TREATMENT  OE  DIABETES  MELLITUS 

a  preponderance  of  animal,  the  achylia  a  prepon- 
derance of  vegetable  food.  We  must  find  a 
way  to  select  the  food  so  that  while  it  is  rich  in 
protein  and  fat  it  still  contains  little  meat. 

In  these  cases  a  trial  of  the  von  Noorden  oat- 
meal cure  would  be  appropriate. 

In  numerous  cases  of  such  a  combination  of 
achylia  and  diabetes  I  have  used  the  following- 
diet  list  with  advantage: 

Calories 

Breakfast:  Three  soft  boiled  eggs 240 

One  roll  (40  grams) 100 

Butter  (30  grams) 251 

Coffee    (200    grams)    and    cream    (50 

grams) 138 

Dinner:       Beef    tea    (200    grams),    with    meat 

powder  (30  grams) 118 

Three  scrambled  eggs 240 

Half  a  roll 50 

Butter  (30  grams) 251 

Spinach  or  asparagus  (50  grams) 82 

Supper:       Two  eggs  beaten  with   150  grams  of 

milk  and  50  grams  of  cream 394 

Mashed  Potato  (50  grams) 63 

Crackers  (10  grams) 24 

Cream  cheese  (20  grams) 79 

Butter  (30  grams) 251 

9:30  P.  M.:  300  grams  of  Kumyss  with  Almonds 

and  nuts 100 

2,381 


118  LECTURES  ON  DIETETICS 

It  is  understood,  of  course,  that  this  diet 
must  be  somewhat  varied.  I  often  use  pea 
soups,  although  they  contain  a  considerable 
amount  of  carbohydrates. 

After  the  patient  has  lived  on  this  diet  for 
about  one  week,  it  is  better  to  add  for  dinner 
some  meat  (chicken,  calf's  brain,  sweetbread  or 
chopped  meat). 

The  main  point  in  the  treatment  of  these 
patients  lies  in  the  fact  that  they  have  to  take 
more  carbohydrates  than  usual  and  that  they 
do  better  under  this  mode  of  treatment. 

The  urine  naturally  must  also  serve  here  as  an 
indicator  to  determine  whether  or  not  the 
amount  of  carbohydrate  is  harmful. 

Another  class  of  digestive  disturbances  occur- 
ring in  diabetics  is  that  of  catarrh  of  the  stomach 
or  bowel.  We  usually  have  to  deal  with  acute 
affections  of  the  stomach  and  bowel,  or  of  both 
organs,  produced  by  overfeeding  with  too  greasy 
or  too  heavy  food. 

In  these  cases  the  dietetic  treatment  must 
be  directed  especially  against  the  acute  affec- 
tions and  we  must  leave  the  diabetes  out  of 
consideration. 

A  bland  meager  diet  is  the  main  thing  (beef 


TREATMENT  OF  DIABETES  MELLITUS  119 

tea,  gruels,  milk,  possibly  raw  eggs  beaten  up  in 
milk  or  beef  tea).  When  the  acute  stage  of  the 
digestive  disturbances  is  passed  we  can  slowly 
return  to  the  antidiabetic  diet. 


LECTURE  IX 

THE  DIETETIC  MANAGEMENT  AND  THE  ALLEN 
TREATMENT  OF  DIABETES  MELLITUS1 

Diabetes  is  a  true  disease  of  disturbed  meta- 
bolism. While  digestion  and  absorption  go  on 
in  a  normal  way,  the  assimilation  of  foods  is  at 
fault.  In  mild  cases,  the  carbohydrates  alone 
cannot  be  utilized.  Instead  of  burning  up  and 
generating  heat  for  the  body  economy,  they  are 
eliminated  from  the  system  in  the  form  of 
sugar  with  the  urine.  In  the  severe  forms,  the 
proteins  are  split  up  partly  into  carbohydrate 
material,  which  latter  again  is  not  burned  up 
but  is  excreted  as  such.  In  the  still  severer 
forms,  fats  (the  third  nutritive  group)  are  like- 
wise broken  up  into  acid  radicals,  which  again 
do  not  oxidize  to  their  ultimate  products,  but 
circulate  for  a  while  in  the  blood  stream  as  such, 
and  are  partly  excreted  with  the  urine  (acidosis) . 
The  glucose,  as  well  as  the  acid  products,  when 
accumulated  in  the  system,  act  as  irritants,  pro- 

1  Read  before  the  N.  Y.  Medical  Union  on  January  23,  1917. 
120 


THE  DIETETIC  MANAGEMENT          121 

ducing  abnormal  conditions  which  give  rise  to 
the  development  of  various  diseases. 

The  treatment  of  diabetes,  therefore,  has  for 
its  object  at  first  the  freeing  of  the  organism  of 
both  sugar  and  acids.  The  management  of 
this  disease, — in  attempting  to  keep  the  body 
free  from  the  above  metabolic  defects, — is  then  a 
question  of  diet,  and  this  has  played  the  greatest 
part  in  the  treatment  of  this  condition  almost 
since  the  discovery  of  the  disease.  Rollo,  in 
1796,  introduced  an  animal  diet  as  a  cure  for 
diabetes,  and  this  treatment  has  been  more  or 
less  rigidly  adhered  to  by  most  clinicians  for  over 
a  century. 

Bouchardat  and  Cantani  recognized  the  evil 
results  of  a  too  liberal  protein  diet,  and  intro- 
duced green  vegetables  as  an  important  factor 
in  the  treatment  of  this  disease.  Naunyn,1 
one  of  the  greatest  investigators  of  diabetes, 
likewise  recognized  the  utility  of  green  vege- 
tables in  the  dietary  regime  of  diabetes,  and 
discovered  the  fact  that  fast  days  produce  bene- 
ficial results,  by  not  only  clearing  up  the  resis- 
tant glycosuria  and  improving  tolerance,  but 
also  by  at  times  warding  off  comatose  conditions. 

1  Naunyn:  Der  Diabetes  Mellitus  Wien,  1906. 


122  LECTURES  ON  DIETETICS 

Von  Noorden  corroborated  Naunyn's  state- 
ments, and  made  use  of  fast  days,  especially 
when  acidosis  was  present.  He  noticed  the 
striking  effect  that  fasting  had  upon  the  fall  of 
acetone.  In  severe  cases  of  diabetes  with  acido- 
sis he  instituted  one  fast  day  every  week,  with 
excellent  results.  Fasting  in  the  treatment  of 
diabetes  has  been  frequently  practised  by  Guelpa1 
of  Paris.  He  insisted  that  the  patient  should 
fast  for  three  days  or  more,  with  a  bottle  of 
Hunyadi  Janos  water  each  day,  followed  first  by 
a  milk  and  then  a  vegetable  diet, — with  occasional 
repetition  of  the  fasting  and  purging.  In  mild 
cases,  Guelpa  noticed  great  benefit  from  this 
treatment. 

While  formerly  most  clinicians  laid  much 
stress  upon  keeping  the  organism  of  the  diabetic 
patient  in  good  condition  and  well  nourished,— 
it  was  believed  to  be  of  essential  importance  to 
look  out  for  a  sufficient  amount  of  food  (see 
Lecture  VIII), — Allen2  was  one  of  the  first  to 
break  away  from  this  maxim  and  to  rather  lay 


1  Guelpa:  British  Medical  Journal,  1910,  ii,  p.  1050. 

1  F.  M.  Allen:  "Studies  Concerning  Diabetes,     Journal  American 
Med.  Association,  1914,  p.  939. 

F.  M.  Allen:  "  The  Treatment  of  Diabetes,"  Boston  Med.  &  Surg. 
Journal,  1915,  p.  743. 


THE  DIETETIC  MANAGEMENT          123 

the  greatest  stress  upon  keeping  the  diabetic 
patient  free  from  sugar, — even,  if  necessary,  at 
the  cost  of  a  loss  of  strength  and  body  weight. 
Allen's  ideas  were  quite  revolutionary,  and  while 
his  treatment  was  not  new  in  every  feature,  it 
represented  on  the  whole  a  great  innovation  and 
marked  a  long  step  in  advance.  From  my  own 
experience  I  can  fully  corroborate  the  state- 
ment which  Joslin1  uttered  in  1915:  "It  is  no 
exaggeration  to  say  that  the  advance  in  the 
actual  treatment  of  diabetes  mellitus  during  the 
twelve  months  just  passed  has  been  greater  than 
in  any  year  since  Hollo's  time." 

Before  outlining  Allen's  plan  of  treatment,  it 
will  be  well  to  state  that  at  present  the  view 
prevails  that  diabetes  mellitus  is  a  disease  caused 
by  a  disturbed  function  of  the  internal  secre- 
tion of  the  pancreas,  the  islands  of  Langerhans 
being  principally  involved.  In  testing  the 
experiences  gained  by  noted  clinicians  in  the 
field  of  diabetes,  Allen  made  numerous  experi- 
ments upon  animals  in  which  the  pancreas  had 
been  to  a  great  extent  extirpated.  He  found 
that  if  the  pancreas  remnant  in  operated  ani- 

1E.  B.  Joslin:  "Present  Day  Treatment  and  Prognosis  in  Diabetes." 
Amer.  Jour,  of  Med.  Sciences,  1915,  p.  485. 


124  LECTURES  ON  DIETETICS 

mals  is  about  one-tenth,  the  diabetes  is  perma- 
nent, even  on  a  meat  diet,  and  usually  ends  fatally. 

A  few  days  of  fasting  at  the  outset,  however, 
will  produce  sugar  freedom.  If  the  diabetes  is 
allowed  to  continue  longer,  a  much  longer  period 
of  fasting  may  be  necessary  for  sugar-freedom, 
or  it  may  be  impossible  to  obtain  it.  If,  after 
obtaining  sugar  freedom,  feeding  of  protein  and 
fat  is  begun  very  cautiously, — in  quantity  only 
enough  to  maintain  the  animal  in  its  thin  condi- 
tion,— such  animals  remain  free  from  diabetes. 
Increasing  the  weight  of  such  an  animal  very 
soon  produces  glycosuria,  which  can  be  checked 
by  renewed  fasting.  Animals  made  diabetic 
by  carbohydrate  diet,  act  in  a  similar  way,— 
i.e.,  they  soon  become  sugar-free,  after  starving 
(F.  M.  Allen:  Studies  concerning  Diabetes). 

Allen  then  gives  the  following  rules:  Make 
patient  sugar-free  by  fasting.  Then  gradually 
increase  the  food,  according  to  the  tolerance,  and 
keep  him  steadily  free  from  sugar.  A  loss  of 
weight  at  first, — especially  in  a  not  too  greatly 
emaciated  individual, — is  desirable.  Never  give 
a  too  high  calorie  diet,  nor  give  too  much  protein. 
(Allen  allows  1  gram  of  protein  per  day  to  a 
kilogram  of  weight).  If  the  patient  has  lost 


THE  DIETETIC  MANAGEMENT          125 

much  in  weight,  he  may  be  allowed,  by  increasing 
the  fat  in  the  food,  to  regain  part  of  it,  provided 
that  no  sugar  reappears  in  the  urine.  As  soon 
as  the  latter  occurs,  he  must  return  to  a  lower 
calorie  diet. 

Exercise  has  been  advocated  as  a  means  of 
furthering  the  combustion  of  the  carbohydrates 
in  the  system.  This  factor  Allen  likewise  utilizes 
in  his  plan  of  treatment.  He  rather  thinks  that 
brisk  exercises  are  more  efficacious  than  the 
milder  forms.  Fatigue,  however,  should  always 
be  avoided. 

With  regard  to  the  details  of  treatment,  Allen 
gives  the  following  rules: 

If  the  patient  is  moderately  emaciated,  with 
a  negative  carbohydrate  balance  and  acidosis, 
he  is  put  to  bed  and  receives  no  food  whatsoever. 
If  coma  seems  imminent,  the  usual  emergency 
treatment,  with  purging,  stimulants,  alkalies, 
and  large  amounts  of  water  should,  of  course,  be 
carried  out.  In  addition  to  fasting,  alcohol  is 
important  in  the  treatment  at  this  stage.  From 
50  to  250  cc.  of  whiskey  or  brandy  may  be  given 
in  each  twenty-four  hours,  in  small  doses,— 
from  10  to  20  cc.,  every  one  to  three  hours  during 
the  twenty-four.  As  soon  as  the  glycosuria 


126  LECTURES  ON  DIETETICS 

stops  and  the  acidosis  diminishes,  which  even 
in  severe  cases  may  be  within  48  to  96  hours,  the 
amount  of  alcohol  and  alkali  may  be  reduced. 
Fasting  and  moderate  dosage  of  alcohol  are 
continued  for  from  twenty-four  to  forty-eight 
hours  longer,  however,  depending  on  the  pa- 
tient's strength.  The  alkali  is  then  stopped,  and 
feeding  with  starch  is  commenced,  in  order  to 
clear  up  the  last  traces  of  ketonuria. 

Green  vegetables  are  useful  because  their  car- 
bohydrate and  food  value  is  so  low  that  they  can 
be  given  in  considerable  bulk,  and  this  bulk  is 
agreeable  to  the  patient  for  relieving  his  feeling 
of  emptiness.  Neither  fat  nor  protein  is  added. 

For  the  first  day,  the  carbohydrate  content  is 
10  to  40  grams,  divided  for  four  equal  feedings, 
during  the  day.  If  glycosuria  remains  absent, 
the  ration  for  the  next  day  is  doubled.  There 
still  being  no  sugar  in  the  urine,  the  ration  on  the 
following  day  may  be  increased  to  100  grams  of 
carbohydrate.  Should  glycosuria  reappear,  an- 
other fast  day  is  interposed, — from  50  to  200 
cc.  of  whiskey  being  given.  Even  severe  cases 
of  ketonuria  may  by  this  method  completely 
clear  up. 

The  carbohydrate  of  the  diet  is  seldom  reduced 


THE  DIETETIC  MANAGEMENT          127 

below  50  grams,  and  is  preferably  kept  higher. 
If  carbohydrate  must  be  kept  low,  the  total  diet 
is  kept  low.  The  diet  is  so  chosen  that  glyco- 
suria,  not  ketonuria,  is  the  signal  of  overstrain. 
Fasting-alcohol  days  are  given  not  merely  when- 
ever this  signal  appears,  but  also  at  close  enough 
intervals  to  prevent  it  from  appearing, — even 
every  two  or  three  days, — if  necessary. 

No  matter  how  low  the  assimilation  power  is, 
no  attempt  should  be  made  to  feed  in  excess  of 
it.  With  the  improvement  in  the  condition  of 
the  patient,  the  carbohydrate  is  increased.  In- 
crease in  weight,  however,  should  not  be  at- 
tempted at  this  time.  The  metabolism  is  kept 
at  the  lowest  safe  level,  until  the  patient  is 
taking  from  100  to  150  grams  of  carbohydrate 
(green  vegetables)  daily,  with  fast  days  inter- 
posed often  enough  to  prevent  any  trace  of 
glycosuria  from  appearing.  The  protein  is 
cautiously  added,  always  being  kept  low.  In 
favorable  cases  the  weight  and  well-being  may 
finally  improve  under  gradual  additions  of  fat. 

In  milder  cases,  the  treatment  may  be  cor- 
respondingly milder.  Primary  loss  of  weight  is 
intentional.  When  there  is  extreme  cachexia 
and  emaciation,  the  difficulty  is  greatest.  The 


128  LECTURES  ON  DIETETICS 

alkali  treatment  is  not  employed  unless  for  a 
brief  period  at  the  outset,  while  severe  acidosis  is 
being  combatted.  Even  very  severe  cases  are 
amenable  to  this  mode  of  treatment.  The  best 
therapy  lies,  however,  in  the  application  of  this 
principle  of  treatment  at  the  earliest  possible 
stage  of  diabetes. 

Severe  acidosis  can  be  considerably  reduced  by 
prolonged  fasting.  Freedom  from  glycosuria 
seems  attainable  in  all  cases  of  uncomplicated 
human  diabetes  before  there  is  danger  of  death 
from  starvation.  No  centra-indication  has  been 
met,  unless  it  be  the  appearance  of  nausea, 
vomiting,  and  prostration  while  fasting.  Just  as 
fasting  is  continued,  not  for  any  limited  number 
of  days  but  as  long  as  necessary  for  sugar-free- 
dom;— so  also  the  diet  is  governed  not  by. any 
theoretical  standard  of  protein  or  calories,  but 
by  the  amount  of  each  food  that  can  be  given  in 
each  case  while  keeping  the  urine  clear.  Under 
this  program,  even  weak  and  emaciated  pati- 
ents have  been  subjected  to  under-nutrition, 
in  both  protein  and  calories  for  weeks  or  months 
continuously,  with  ultimate  benefit.  Any  trace 
of  sugar  is  the  signal  for  a  fast  day,  with  subse- 
quent modifications  of  diet;  and  routine  fast 


THE  DIETETIC  MANAGEMENT          129 

days  are  often  used  as  frequently  as  once  a  week, 
even  in  absence  of  glycosuria. 

Two  principles  are  important  in  the  manage- 
ment of  severe  cases :  To  keep  the  patient  per- 
manently below  weight,  and  to  restrict  the 
quantity  of  fat  in  the  diet.  The  reduction  in 
weight  is  beneficial  to  the  diabetic  patient, 
serving  to  spare  the  weakened  'function  and 
increase  tolerance.  Sometimes  a  slight  reduc- 
tion of  weight  suffices  even  for  a  severe  case. 
Again,  a  well-nourished  patient,  easily  kept  free 
from  glycosuria,  had  to  be  reduced  by  20  kilo- 
grams merely  because  of  a  slight  stubborn 
ketonuria  and  a  persistently  high  blood  sugar. 
Most  patients  are  able  to  regain  weight,  but 
few  severe  ones  are  able  to  return  fully  to  normal 
weight.  Any  increase  that  is  possible  without 
return  of  symptoms  is  permitted.  Any  gain 
that  brings  back  glycosuria  or  ketonuria  is 
checked.  The  overtaxing  of  the  patient's  me- 
tabolism by  giving  fat  beyond  the  limit  of 
tolerance  is  an  additional  explanation  of  the 
failure  to  keep  certain  patients  free  from  glyco- 
suria and  ketonuria  under  former  methods  of 
treatment.1 

1F.   M.  Allen:  "Prolonged  Fasting  in  Diabetes."  Am.  Jour.  Med. 
Sciences,  1915,  p.  480. 
0 


130  LECTURES  ON  DIETETICS 

I  have  used  the  alcohol  during  the  fasting 
period  with  but  a  limited  number  of  patients. 
Most  of  them  do  well  without  it.  Bouillon, 
coffee,  tea,  and  plenty  of  water  are  the  essential 
ingredients  needed  during  the  fast. 

The  following  regime  may  be  observed: 

1.  The  patient  is  made  to  fast  until  the  urine 
is  sugar-free.     During  this  time  he  takes  a  cup 
of  tea  in  the  morning  (8  A.  M.) ;  one  to  two  cups 
of  -bouillon   at  noon  (12:);  one   cup   of  coffee 
at  4   P.   M.;  and  one  to  two  cups  of  bouillon 
at    8    P.    M.     In    between,   he   is   encouraged 
to  drink  one  and  a  half  to  two  quarts  of  water, 
or  Apollinaris  or  Vichy.     He  is  allowed  to  walk, 
part  of  the  time  and  to  busy  himself  with  read- 
ing,   etc.,   but   he   must   be  warned  not  to  get 
over-tired.     When  fatigued  he  should  rest  in  a 
rocking  chair  or  in  bed. 

2.  The  urine  having  become  free  from  sugar, 
feeding  with  green  vegetables  is  begun. 

3.  As    soon    as    the    carbohydrates    can    be 
given  in  an  amount  of  about  80  to  100  grams 
a   day    without   the    appearance    of    sugar   in 
the    urine,    protein    is    given, — at    first    about 
20  grams  (three  eggs)  a  day.     Thereafter  the 
protein  is  increased  by  about  5   grams  a  day 


THE  DIETETIC  MANAGEMENT          131 

until  1  gram  of  protein  per  kilo  of  body  weight 
is  reached. 

4.  This  protein  usually  includes  a  small  amount 
of  fat,  especially  when  eggs  are  eaten,  but  besides 
this  amount  fat  is  slowly  added  as  such,  by 
adding  butter,  cream  or  bacon  to  the  diet.     The 
amount  of  fat  is  slowly  but  steadily  increased, 
— provided  there  is  no  ketonuria  noticeable,— 
until  the  loss  of  weight  is  checked.     The  patient 
should,  however,  never  get  more  than  30  to  40 
Calories  per  kilo  weight  a  day. 

5.  Whenever  sugar  reappears  in  the  urine,  a 
fast  day  should  immediately  be  instituted.     This 
will  usually  be  enough  to  clear  the   urine  of 
sugar.     The  diet  is  then  resumed  as  before, — but 
about    half    the    amount  of    carbohydrates    is 
given   at   first,    and   then   gradually   increased 
again.     But  even  if  the  patient  continues  sugar- 
free,  one  fast  day  a  week  should  be  maintained, 
especially  in  the  severer  forms  of  diabetes.     In 
mild  cases,  this  fast  day  can  be  replaced  by  one 
green  vegetable  day  weekly, — the  diet  consisting 
merely  of  bouillon  and  green  vegetables  or  salads. 

Within  the  last  two  years,  I  have  applied  the 
Allen  treatment  in  twenty  cases  of  diabetes 
mellitus, — most  of  them  were  in  the  German 


132  LECTURES  ON  DIETETICS 

Hospital;  a  few  in  the  Post-Graduate  and  in  my 
private  practice, — and  have  been  satisfied  with 
the  results.  In  most  instances  the  urine  became 
free  from  sugar  on  the  third  or  fourth  day  of 
fasting.  Usually  the  patients  stand  the  fasting 
period  without  much  trouble.  In  one  instance, 
however,  this  mode  of  treatment  could  not  be 
carried  out.  The  patient  referred  to  was  a  lady 
of  about  thirty-four,  who  had  diabetes  of  the 
mild  type.  On  the  second  day  of  fasting  I  found 
her  in  a  condition  of  extreme  collapse.  She  was 
hardly  able  to  talk  and  almost  lifeless.  At  the 
time,  I  and  the  other  physicians  in  the  hospital 
considered  her  death  near.  Alkalies  were  given 
to  her  per  rectum  and  stimulants  applied,  and 
at  the  same  time  the  patient  was  encouraged  to 
take  nourishment  regardless  of  its  character. 
It  took  about  four  or  five  days  of  this  mode  of 
treatment  to  have  the  patient  recuperate  from 
her  severe  attack  of  shock.  This  shows  that 
extreme  care  is  required  during  the  fasting  period. 
In  the  treatment  of  diabetes,  the  examination 
of  the  urine  for  sugar  and  acetone  plays  a  most 
important  part,  especially  with  regard  to  the 
arrangement  of  the  diet.  For  this  reason  I 
consider  it  advantageous  to  describe  here  the 


THE  DIETETIC  MANAGEMENT          133 

most  important  tests  for  sugar  and  the  acid 
bodies  in  the  urine.  Some  clinicians  consider 
it  essential  to  teach  the  diabetic  patients  to 
perform  these  tests  for  themselves.  This  will 
not  always  be  necessary,  but  will  occasionally  be 
quite  appropriate.  For  the  qualitative  and 
quantitative  determination  of  sugar,  the  Bene- 
dict test  is  very  convenient. 

Benedict's  Teat 

Sol.  A  Sol.  B 

Ammon.  sulphate..  1.2  gram 


Copper  sulphate...  2.6    grams. 
Aquae  destill 50  c.c. 


Potass,    hy- 
drate      20  grams. 

Glycerin 100  (grams.)  cc. 


Aq.   animo- 

nise 250  (grams.)  cc. 

(S.G.  0.90) 
Aquae  destill: 

(    ad... 500  cc. 

Mix  in  proportion  of  Sol.  A  1  part:  Sol.  B  9  parts. 
Use  4  cc.  of  this  solution. 

Boil — and  add  urine  drop  by  drop,  with  medicine  dropper  (gtt.  18  = 
1  c.c.)  until  the  blue  coTor  disappears  completely. 

Solution  4  cc. 

Urine:  gtt.   Sugar,  per  cent 


1 

= 

6.0 

2 

= 

3.0 

3 

= 

2.0 

4 

= 

1.5 

5 

= 

1.2 

6 

= 

1.0 

7 

• 

0.85 

8 

= 

0.75 

9 

= 

0.66 

10 

= 

0.6 

12 

= 

0.5 

24 

= 

0.25 

134 


LECTURES  ON  DIETETICS 


This  test,  although  quite  accurate,  has  the 
disadvantage  that  it  is  based  upon  reduction, 
which  is  not  specific  for  sugar,  as  there  exist 
other  reducing  substances  in  the  urine  which 
may  give  rise  to  mistakes. 

The  fermentation  test,  which  can  be  easily 


FIG.  1. — Einhorn's  fermentation  saccharometer.  The  fermentation 
saccharometer  can  be  obtained  at  Eimer  &  Amend,  205  3rd.  Ave.,  New 
York. 

performed  with  the  Fermentation  Saccharo- 
meter, is  the  most  positive  proof  of  sugar,  and 
herewith  directions  for  its  use  are  given. 

Take  1  gram  of  commercial  compressed  yeast  (or  ^f  6  of  &  cake 
of  Fleischmann's  Yeast)  shake  thoroughly  in  the  graduated  test  tube 
with  10  cc.  of  the  urine  to  be  examined.  Then  pour  the  mixture  into 
the  bulb  of  the  saccharometer.  By  inclining  the  apparatus  the  mix- 
ture will  easily  flow  into  the  cylinder,  thereby  forcing  out  the  air. 


THE  DIETETIC  MANAGEMENT          135 

Owing  to  the  atmospheric  pressure  the  fluid  does  not  flow  back  but 
remains  there. 

The  apparatus  is  to  be  left  undisturbed  for  twenty  to  twenty-four 
hours  in  a  room  of  ordinary  temperature. 

If  the  urine  contains  sugar,  the  alcoholic  fermentation  begins  in  about 
twenty  or  thirty  minutes.  The  evolved  carbonic  acid  gas  gathers  at 
the  top  of  the  cylinder,  forcing  the  fluid  back  into  the  bulb. 

On  the  following  day  the  upper  part  of  the  cylinder  is  filled  with 
carbonic  acid  gas.  The  changed  level  of  the  fluid  in  the  cylinder  shows 
that  the  reaction  has  taken  place  and  indicates  by  the  numbers — to 
which  it  corresponds — the  approximate  quantity  of  sugar  present. 

If  the  urine  contains  more  than  1  per  cent,  of  sugar,  it  must  be 
diluted  with  water  before  being  tested. 

Diabetic  urines  of  straw  color  and  a  specific  gravity  of  1.018-1.022 
may  be  diluted  twice;  of  1.022-1.028,  five  times;  1.028-1.038,  ten  times. 

The  original  (not  diluted)  urine  contains  in  proportion  to  the  dilution 
two,  five  or  ten  times  more  sugar  than  the  diluted  urine. 

In  carrying  out  the  fermentation  test,  it  is  always  recommended  to 
take  besides  the  urine  to  be  tested,  a  normal  one,  and  to  make  the  same 
fermentation  test  with  it. 

The  mixture  of  the  normal  urine  with  the  yeast  will  have  on  the' 
following  day  only  a  small  bubble  on  the  top  of  the  cylinder.  This 
proves  at  once  the  efficacy  and  purity  of  the  yeast. 

Likewise  if  there  is  in  the  suspected  urine  a  small  bubble  on  the  top 
of  the  cylinder,  then  no  sugar  is  present,  but  if  there  is  a  much  larger 
gas  volume,  then  we  are  sure  that  the  urine  contains  sugar. 

Usually  it  is  necessary  to  wait  over  night  to 
determine  the  amount  of  sugar  present.  This 
is  quite  a  disadvantage.  Qualitatively,  however, 
— and  this  is  really  the  most  important  point  to 
ascertain, — it  is  possible  to  discover  the  presence 
of  sugar  within  half  an  hour  after  performing 
the  test.  In  my  paper  entitled  "Zum  Gahrungs- 
sacharometer,"1  I  showed  that  1  per  cent,  of 

^eutsch.  Med.  Wochenschr.  1891,  No.  13. 


136  LECTURES  ON  DIETETICS 

sugar,  and  even  less,  down  to  Y±  per  cent,  can 
be  positively  recognized  after  a  half  hour's 
time.  One-tenth  of  1  per  cent  of  sugar  can 
be  recognized  after  one  hour,  provided  the  test  is 
made  with  a  control  specimen  of  normal  urine  at 
the  same  time.  In  the  urine  containing  sugar 

A  =  Control  Urine  T  =  26,4°  C. 

B  =  1%  Sugar  Urine 


After  15  Minutes  A  =     "•       ;  B  =  %  ccm;  C  = 

"30        "        A  =      *f     ;  B  =  1  ccm;  C    over  Vfe  ccm. 


Fio.  2  —  The  bubbles  forming  on  the  top  of  saccharometer  soon  after 
performing  the  test. 


a  few  bubbles  appear  at  the  top  of  the  sac- 
charometer pretty  soon  after  the  test  has  been 
performed.  I  herewith  give  an  illustration  of 
the  tiny  bubbles  forming,  taken  from  the  paper, 
just  mentioned. 

With  regard  to  ketonuria,  the  following  tests 
are  of  importance: 


THE  DIETETIC  MANAGEMENT          137 

Acetone  Test 

Urine,  5  cc. 

Acidify  with  glacial  acetic  acid. 

Add  few  drops  sol.  sod.  nitroprusside  (aqueous)  10  per  cent. 

Shake. 

Add  ammonia  hydrate  until  alkaline. 
Reaction  =  Purple  color  indicates  acetone. 

Diacetic  Acid 
Urine,  5  cc. 

Add  excess  of  ferric-chloride. 
Reaction  =  Burgundy  red  indicates  diacetic  acid. 

Quant.  Ammonia  Tett 

Urine,  5  cc. 

Add  1  cc.  of  sat.  sol.  potass,  oxalate. 

Add  gtt.  2  sol.  phenolphthalein. 

Add  N/10  NaOH  to  faint  pink  color. 

Add  1  cc.  formalin  (neutral). 

Add  N/10  NaOH  to  faint  pink  color. 

Each  cubic  centimeter  of  N/10  NaOH  used  in  last  titration  =  1  cc. 
N/10  ammonia  or  .0017  grams,  ammonia. 

Multiply  this  by  number  of  cubic  centimeter  N/10  NaOH  used  in 
last  titration  =  Number  of  grams,  of  ammonia  in  5  cc.  urines. 

In  order  to  more  easily  arrange  the  bill  of 
fare  for  the  diabetic  patient,  two  tables  of  the 
most  common  foods  are  herewith  given,  one 
arranged  according  to  the  per  cent  of  carbo- 
hydrate after  Joslin,  the  other  stating  the 
content  of  the  nutritive  material, — proteins, 
carbohydrates,  and  fats  (caloric  value). 


138 


LECTURES  ON  DIETETICS 


I.  FOODS  ARRANGED   ACCORDING   TO  PER  CENT  OF  CARBOHYDRATE 

(Joalin  >) 


Vegetables* 

(fresh  or  canned) 

5  per  cent 

10  per  cent 

15  per  cent 

20  per  cent 

Lettuce           Tomatoes 

Pumpkin 

Green  peas 

Potatoes 

Cucumbers      Brussels  sprouts 

Turnip 

Artichokes 

Shell  beans 

Spinach           Water  cresa 

Kohl-rabi 

Parsnips 

Baked  beans 

Asparagus       Sea  kale 

Squash 

Canned      lima 

Green  corn 

Rhubarb         Okra 

Beets 

beans 

Boiled  rice 

Endive             Cauliflower 

Carrots 

Boiled  maca- 

Marrow          Egg  plant 

Onions 

roni 

Sorrel               Cabbage 

Mushrooms 

Sauer  kraut     Radishes 

Beet  greens    Leeks 

Dandelions     String  beans 

Swiss  chard     Broccali 

Celery 

Fruitt 

Ripe  olives  (20  per  cent  fat) 

Lemons 

Apples 

Plums 

Grape  fruit 

Oranges 

Pears 

Bananas 

Cranberries 

Apricots 

Prunes 

Strawberries 

Blueberries 

Blackberries 

Cherries 

Gooseberries 

Currants 

Peaches 

Raspberries 

Pineapple 

Huckleberries 

Watermelon 

Nutt 

Butternuts 

Brazil  nuts 

Almonds 

Peanuts 

Pignolias 

Black  walnuts 

Walnuts— 

Hickory 

(English) 

Pecans 

Pistachios 

40  per  cent 

Filberts 

Pine  nuts 

Chestnut* 

Miscellaneous 

Unsweetened    and   unspiced 
Pickle,   clams,   oysters,   scal- 
lops, liver,  fish  roe 


1  Reckon  available  carbohydrates  in  vegetables 

of  5  per  cent  group  as  3  per  cent. 
Reckon  available  carbohydrates  in  vegetables 

of  10  per  cent  group  as  6  per  cent. 


*E.  P.  Joslin:      The  Treatment  of  Diabetes  Mellitus,"  Phila.,  1916. 

As  an  example  of  the  management  of  diabetic 
cases,  I  give  the  exact  bill  of  fare  of  patient  P.  dur- 
ing her  stay  in  the  German  Hospital.  (See  pp. 
140-146.) 


THE  DIETETIC  MANAGEMENT 


139 


II.  TABLE  OF  FOODS  FREQUENTLY  USED  IN  DIABETES:  WITH  NUTRI- 
TIVE VALUES  IN  100  GRAMES 


Protein, 
grams 

Fat, 
grams 

Carbo- 
hydrate, 
grams 

Total, 
calories 

Asparagus  (canned)  

2.0 

1.0 

3.0 

30.0 

String  beans  (fresh  cooked) 
Lettuce  (raw)  

1.0 
1.0 

1.0 
0.3 

2.0 
3.0 

22.0 
19.0 

Cauliflower   (raw)  

2.0 

0.5 

5.0 

33.0 

Spinach  

2.0 

0.3 

3.0 

23.0 

Green  peas  (raw)  

7.0 

0.5 

16.0 

99.0 

Potatoes  (white)  

2.0 

0.1 

18.0 

83.0 

Peas  (dried)  

24.0 

1.0 

62.0 

362.0 

Butter4    .            

84.0 

780.0 

Milk  (whole)    

3.0 

4.0 

5.0 

70.0 

Milk  (skim)  

3.0 

0.3 

5.0 

35.0 

Cheese  (neufchatel)  "2K 
X  1%  X  1>£"  

16.0 

23.0 

1.0 

284.0 

Cream  (gravity)  

3.0 

16.0 

5.0 

181.0 

Bacon  (raw)  4  slices,  6  X 
2                 

10.0 

64.0 

636.0 

Bacon   (cooked)   4   slices, 
6X2  

10.0 

46.0 

468.0 

Eee3 

14.0 

12.0 

168.0 

Oysters  (6  large)  

6.0 

1.0 

3.0 

46.0 

Oatmeal  (cooked)  

3.0 

0.5 

12.0 

66.0 

Rice  (cooked)   

3.0 

0.1 

24.0 

112.0 

Bread  

7.0 

0.5 

55.0 

260.0 

Grapefruit*            

0.6 

10.0 

43.0 

Orange  *        

0.7 

9.0 

38.0 

Watermelon  

0.4 

0.2 

7.0 

32.0 

Bananas          

1.0 

0.6 

22.0 

100.0 

Walnuts  

18.0 

64.0 

13.0 

722.0 

Almonds             .  .          .... 

21.0 

54.0 

17.0 

658.0 

Peanuts               

25.0 

38.0 

24.0 

546.0 

1  Small  fruit  =  300  grams. 

*  Medium  fruit  =  150  grams. 
3  1  Egg  (medium)  =  50  grams. 

*  One-forth-inch  cube  =  30  grams. 


140 


LECTURES  ON  DIETETICS 


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LECTURE  X 
THE  DIETETIC  MANAGEMENT  OF  GOUT 

Luxurious  living  and  to  a  certain  degree  an 
abuse  of  alcohol  have  been  recognized  as  playing 
a  part  in  the  origin  of  gout.  Accordingly  up  to 
within  the  last  twenty  years  an  abstemious  diet 
consisting  principally  of  vegetables  and  the 
exclusion  of  alcoholic  beverages  formed  the 
principal  part  of  the  dietetic  treatment  of  this 
disease. 

In  gouty  conditions  uric  acid  deposits  can  be 
discovered  in  various  parts  of  the  body  (princi- 
pally the  joints,  connective  tissue,  and  bones). 
Garrod1  showed  the  presence  of  uric  acid  in  the 
blood  of  the  gouty,  thus  revealing  the  relation- 
ship of  uric  acid  to  this  disease.  The  origin  of 
the  uric  acid  had  been  believed  to  be  a  metabolic 
product  of  the  albuminates,  similar  to  urea. 

This  appeared  to  confirm  the  necessity  of  re- 
stricting the  protein  foods  generally  in  the  diet  of 
gout. 

1  A.  B.  Garrod:  Nature  and  Treatment  of  Gout,     Wtirzburg,  1861. 

147 


148  LECTURES  ON  DIETETICS 

A  change  of  this  view  has  been  accomplished 
by  the  important  investigations  and  the  great 
discoveries  in  the  metabolic  process  of  the  nucleo- 
proteins,  by  Miescher1  and  Kossel,2  Horbac- 
zewski,3  Schittenhelm,4  E.  Fischer,5  Brugsch,6 

Wiener,7    Bessau    and    Schmid8    and    C.    von 
Noorden.9 

It  has  been  shown  by  these  investigators  that 
uric  acid  as  well  as  all  nucleoproteins  (both 
animal  and  vegetable)  contain  in  their  chemical 
construction  a  common  atom  group,  the  so- 
called  "purin  ring"  of  five  C  (carbon)  and  four 
N  (nitrogen)  atoms.  The  same  experiments 
have  proven  that  uric  acid  ^H^N^s)  or 
trioxypurin  is  derived  in  the  metabolic  process 

1  F.  Miescher:  Physiologisch-chemische  Untersuchungen  iiber  die 
Lachsinilch  Arch.  f.  exper.  Pathol.  und  Pharmak.,  1895,  vol.  37,  p.  100. 

*  A.  Kossel :  Untersuchungen  tiber  die  Nucleine  und  deren  Spalt- 
produkte,  Strassburg,  1881. 

*J.  Horbaczewski :  Untersuchunden  liber  die  Entstehung  der 
Harnsaure.  Monatshefte  f.  Chemie,  x,  1889,  p.  624. 

4  A.  Schittenhelm:  Der  Nukleinstoffweehsel.  Handbuch  der  Bio- 
chemie  (C.  Oppenheimer)  1910,  iv,  p.  489. 

'E.  Fischer:  Untersuchungen  tiber  die  Puringruppe,  Berlin,  1907. 

•T.  L.  Brugsch:  See  Brugsch  und  Schittenhelm.  Der  Nuklein- 
stoffwechsel  und  seine  Stoerungen,  June,  1910. 

7  H.  Wiener:  Die  Harnsaure  in  ihrer  Bedeutung  flir  die  Pathologic. 
Ergebnisse  der  Physiol.,  1903,  11  i  Abt.,  p.  377. 

8G.  Bressau  und  J.  Schmid:  Die  Diatetik  bei  harnsaurer  Diathese 
und  Gicht.  Therap.  Monatsheft,  1910,  v.  24,  p.  116. 

*C.  von  Noorden,  Die  Gicht:  Lehrbuch  der  Pathol.  des  Stoffwechsels. 
ii,  Aufl.,  Bd.  ii,  p.  138,  Berlin,  1907. 


DIETETIC  MANAGEMENT  OF  GOUT     149 

of  the  nucleoprotein  digestion  by  ferment  action. 
Normally  the  uric  acid  derived  in  the  body  of 
the  nucleinic  acid  is  partly  still  further  changed 
to  products  not  yet  known,  while  some  of  it 
between  40-50  per  cent,  sometimes  much  less, 
appears  in  the  urine  as  such. 

The  uric  acid  originating  from  the  nuclei  of 
the  body  cells  proper  is  designated  as  "endo- 
genous" while  that  derived  from  the  outside 
material  (animal  or  vegetable  foods  containing 
purin  bodies)  as  "exogenous." 

In  health,  when  living  on  a  purin-free  diet, 
the  blood  does  not  reveal  the  presence  of  uric 
acid.  After  a  purin-rich  diet  there  appears  in 
the  blood  uric  acid  for  a  short  period,  but  very 
soon  it  is  totally  eliminated  with  the  urine,  and 
becomes  free  again. 

In  gouty  individuals  this  is  quite  different. 
The  blood  always  shows  the  presence  of  uric 
acid  even  when  no  purin  foods  have  been  indulged 
in  for  a  long  time.  Again,  after  a  purin-rich  diet 
the  healthy  reacts  differently  from  the  gouty. 

After  such  an  event  the  normal  individual 
shows  quickly  for  a  short  while  uric  acid  in  the 
blood  "uricemia"  which  is  followed  by  an 
increased  elimination  of  this  exogenous  uric 


150  LECTURES  ON  DIETETICS 

acid  with  the  urine.  The  gouty  on  the  other 
hand  develops  an  increase  of  his  usual  uricemia 
but  slowly  and  the  exogenous  uric  acid  is  not 
eliminated  by  the  kidneys  quickly  but  at  a 
much  slower  rate  and  imperfectly. 

Following  the  teachings  of  Brugsch,  Schitten- 
helm  and  Schmid  in  gout  the  entire  cycle  of  the 
purin  metabolism  is  disturbed.  The  organism 
is  not  able  to  manufacture  or  destroy  the  uric 
acid  products  as  efficiently  as  in  health. 

The  above  explanations  make  it  clear  that  in 
addition  to  the  former  dietetic  management  of 
gout  a  new  principle  will  have  to  be  added 
namely  a  purin-f ree  diet. 

Just  the  same  as  in  diabetes  mellitus,  abstin- 
ence of  starchy  foods,  totally  or  to  a  certain 
degree,  according  to  the  existing  tolerance,  is 
the  mainstay  of  the  treatment,  so  in  gout  the 
restriction  of  purin  foods  forms  the  essential 
part  of  the  regime. 

The  dietetic  management  of  the  gouty  will 
culminate  in  two  principles : 

1.  Increased  metabolism  and  elimination  of 
the  purin  bodies. 

2.  Strict    avoidance    or     diminution    of  the 
ingestion  of  purin-containing  foods. 


DIETETIC  MANAGEMENT  OF  GOUT     151 

The  first  point  is  best  accomplished  by  flushing 
the  system  with  fluids  (water),  and  gradually 
increased  muscular  exercises  (walking,  massage, 
vibratory  massage,  electro-  and  hydrotherapy ) ; 

The  second  point  consists  in  a  strict  observ- 
ance of  a  purin-free  diet  for  a  more  or  less  pro- 
longed period  of  time. 

In  order  to  facilitate  a  dietary  plan  in  gout  we 
give  in  the  following  Schmid  and  Bessau's  table 
of  the  purin  content  of  the  more  important 
common  foods: 


TABLE  OF  THE  PUHIN  CONTENT  OF  THE  COMMON  FOODS  (AFTER  BESSAU 
AND  SCHMID  J) 


100  grains 

Amount  of  purin 
bodies  in  grams 

The  purin  bodies 
computed  as  rep- 
resented in  uric 
acid  in  grams 

Meats 


Beef  

0  0375 

0  111 

Calf       

0  0385 

0  114 

Mutton  

0  0265 

0  078 

Pork  

0  0412 

0   123 

Tongue  (calf)  .    . 

0  0552 

0   165 

0  0380 

0   114 

0  0235 

0  069 

Blood  sausage  

0  059 

0  045 

0  0282 

0  084 

0  0935 

0  279 

0.0804 

0  240 

Thymus  (calf)  

0  330 

0  990 

0  0525 

0   156 

Chicken  

0  .  0292 

0  087 

0  0585 

0  174 

Goose     

0  .  0336 

0  099 

Deer  

0.0393 

0  177 

0  .  0345 

0  012 

1  Cited  after  Schittenhelm  &  Schmid:  Die  Gicht  und  ihre  diatetische  Therapie. 
Albu's  Verdsunngs-und  Stoffwechselkrankh,  ii,  Heft  7,  1910, 


152 


LECTURES  ON  DIETETICS 


100  grams 


Amount  of  pur  in 
bodies  in  grams 


The  purin  bodies 
computed  as  rep- 
resented in  uric 
acid  in  grams 


Fith 


Haddock 0.0392 

Tench 0.0271 

Codfish 0 . 0387 

Eel  (smoked) 0. 276 

Salmon  (fresh) 0.0244 

Carp 0.0542 

Pike  perch 0.0468 

Pickerel 0.0485 

Herring 0.0690 

Trout 0.0565 

Sardines 0. 1182 

Sardelles 0.0780 

Anchovis 0. 1450 

Crawfish 0.0200 

Lobster 0.0228 

Oysters 0 . 0297 

Eggt 

Chicken  eggs I  0 

Caviar I  0 

M ilk  and  Cheese 

Milk 0 

Edam  cheese 0 

Swiss  cheese 

Roquefort  cheese 

Gervais  cheese 0 

Cream  cheese 0. 0056 

Vegetables 

Cucumbers 0 

Lettuce 0. 0030 

Radishes 0.0052 

Cauliflower 0.0084 

Shives traces 

Spinach 0.0244 

White  cabbage 0 

Carrots 0 

Rampion 0.0115 

Kohl-rabi 0.0113 

Celery 0 . 0056 

Asparagus 0. 0081 

Onions 0 

String  beans 0. 0021 

Potatoes 0.0026 

Mushrooms 

Pepper  mushroom 0.0185 

Morils 0.0112 

Champignons 0.0051 

Fruits 

Bananas 0 

Pineapples 0 

Peaches 

Grapes 0 

Tomatoes 0 

Pears 0 

Prunes 0 

Cranberries 0 


0.117 
0.084 
0.144 
0.081 
0.072 
0.162 
0.135 
0.144 
0.207 
0.168 
0.354 
0.234 
0.465 
O.O(X) 
0.066 
0.087 


0 
0 
0 
0 
0 
0.015 


0 

0.009 

0.013 

0.024 

traces 

0.072 

0 

0 

0.033 

0.033 

0.015 

0.024 

0 

0.006 

0.00(1 


0.054 
0.033 
0.015 


DIETETIC  MANAGEMENT  OF  GOUT     153 


100  grams 


Amount  of  purin 
bodies  in  grams 


The  purin  bodies 
computed  as  rep- 
resented in  uric 
acid  in  grams 


Oranges 0 

Apricots 0 

Blue  berries 0 

Apples 0 

Almonds 0 

Hazel  nuts 0 

Walnuts 0 

Leguminous  Fruits 

Green  peas 0.0274 

Dried  peas 0.0185 

Beans 0.017 

Cereals 

Farina 0 

Barley 0 

Rice 0 

Tapioca 0 

Sage 0 

Oatmeal 0 

Mllet 0 

Breads 

Rolls 0 

White  bread 0 

Ammunition  bread trace 

Pumpernickel 0. 0035 

Beverages 

Kulmbacher  beer» 0.0010 

Plain  beer1 0.0040 

Rum 0 

Claret 0 


0.081 
0.162 
0.051 


0 
0 

trace 
0.009 


0.012 
0.003 
0 
0 


>  In  one  liter. 

In  looking  over  the  above  table  it  is  evident 
that  all  the  glandular  organs  of  the  animal  body 
are  rich  in  purin  bodies:  thus  thymus  (or  sweet 
bread)  contains  0.3%,  liver  0.09%, kidney 0.08%. 
There  is  not  much  difference  in  the  purin  content 
of  dark  and  white  meats  or  between  meat  of 
animals  or  fish. 

Eggs  (all  kinds  including  caviar),  milk  and  its 
products  (kumyss,  cheese)  all  kinds  of  fruits 


154  LECTURES  ON  DIETETICS 

(also  nuts),  and  cereals  and  their  products 
(bread  and  rolls),  are  purin  free. 

Leguminous  vegetables  are  rich  in  purin, 
especially  lentils,  containing  0.05%.  Of  the 
beverages  clarets  and  rum  are  purin  free,  while 
beer  contains  0.0004%  purin  bodies.  Coffee, 
tea,  and  cocoa  are  rich  in  purin. 

The  above  items  with  regard  to  the  purin  con- 
tent of  the  different  foods  and  drinks  make  it 
easy  to  arrange  a  diet  for  the  gouty. 

In  doing  this  it  is  best  to  separate  the  dietary 
regime  for  the  acute  attack  of  gout  and  that  for 
the  chronic  state. 

THE  DIET  IN  ACUTE  GOUT 

Strictly  purin-free  liquid  and  semisolid  foods 
will  have  to  be  given.  Milk,  gruels,  mineral 
waters,  orangeade,  lemonade  and  fruit  gelees 
will  form  the  main  diet.  Patient  should  ingest 
2-3  quarts  of  fluids  daily. 

As  soon  as  the  severe  pains  have  subsided  and 
the  appetite  has  returned  additions  to  the  above 
bill  of  fare  of  crackers,  and  toast  with  butter, 
cereals,  and  eggs  are  instituted. 


DIETETIC  MANAGEMENT  OF  GOUT     155 
THE  DIET  IN  CHRONIC  GOUT 

A  purin-free  diet  just  sufficient  to  introduce 
enough  calories  to  keep  the  patient  from  losing 
forms  the  principal  plan  of  the  regime. 

The  reason  why  a  liberal  quantity  of  food 
(overnutrition)  is  not  permissible,  lies  in  the 
fact  that  sumptuous  living  favors  an  increase  of 
the  endogenous  uric  acid  formation.  Simple 
living  and  scanty  food  with  plenty  of  water 
diminishes  the  amount  of  endogenous  uric  acid 
developed  in  the  organism  and  increases  its 
elimination. 

Purin-free  foods  should  first  be  given.  Later 
on  foods  containing  small  quantities  of  purin 
bodies  can  be  added  to  the  purin-free  diet. 
Purin-free  food  days  should  be  interposed  at 
certain  intervals,  depending  upon  the  patients 
ability  to  keep  his  blood  free  from  uric  acid. 

A  purin-free  bill  of  fare  is  the  following: 

Breakfast. — Oatmeal  with  cream,  rolls  and 
butter,  honey;  a  cupful  or  two  of  milk. 

Lunch. — An  orange  or  pear  or  baked  apple: 
Eggs  boiled  or  scrambled;  bread  and  butter; 
boiled  cucumber,  or  carrots  or  white  cabbage; 
rice  with  milk,  cheese  and  crackers. 

Dinner. — Cream  soup  with  tapioca,  sago  or 


156  LECTURES  ON  DIETETICS 

farina;  scrambled  eggs  or  omelettes;  rolls  and 
butter;  caviar;  boiled  onions  or  carrots;  banana 
with  cream;  almonds  and  nuts;  butter  milk. 

As  soon  as  a  diet  containing  a  small  amount  of 
purin  bodies  is  permissible  the  following  foods 
can  be  added:  brown  cabbage,  asparagus,  pota- 
toes, celery,  chicken,  mutton;  salmon,  eel, 
oysters,  lobster. 


LECTURE  XI 
THE  DIET  IN  THE  DISEASES  OF  THE  KIDNEYS 

The  kidneys  are  entrusted  by  the  organism 
with  two  very  important  functions:  (1)  to 
excrete  waste  products,  unnecessary  material, 
and  superfluous  fluids  (water)  from  the  body; 
(2)  to  retain  all  material  valuable  to  the  system. 
The  blood  in  passing  through  the  glomeruli  is 
subjected  to  a  scrutinous  examination  by  the  renal 
cells,  and  the  double  function  just  mentioned  is 
in  this  way  carried  out. 

In  disturbances  of  the  kidneys  two  sets  of 
phenomena  are  noticeable:  (a)  accumulation 
in  the  blood  of  substances  which  should  have 
been  eliminated;  (6)  excretion  from  the  blood 
of  material  that  should  have  been  retained. 

The  symptoms  encountered  in  renal  affections 
are  all  more  or  less  dependent  upon  the  above 
two  factors,  which  are  present  either  in  associ- 
ation with  each  other  or  separately.  The  grav- 
ity of  the  disease  is  likewise  subject  to  the  extent 
of  functional  failure  in  these  two  directions. 

1  The  Medical  Clinics  of  North  America,  November,  1917. 
157 


158  LECTURES  ON  DIETETICS 

Alimentation  which  consists  in  the  introduc- 
tion and  working  up  of  new  nutritive  material 
manifestly  increases  the  difficulties  against  which 
the  kidneys  have  to  battle.  The  importance 
of  diet  has  therefore,  always  been  recognized  as 
one  of  the  principal  factors  in  the  treatment  of 
renal  affections. 

I  chose  this  subject  for  discussion  on  accounl 
of  the  many  interesting  points  it  presents  to 
the  clinician. 

The  views  regarding  nephritis  have  undergone 
many  changes  in  the  course  of  the  last  century. 
At  first  it  was  generally  believed  that  the  main 
object  of  diet  should  consist  in  replenishing  the 
lost  albumen  and  for  this  reason  richly  protein 
foods  (meats)  were  given.  Soon,  however, 
it  was  discovered  that  under  this  regime  the 
nephritics  did  not  show  the  desired  improvement, 
and  rather  became  worse.  This  led  to  the  selec- 
tion of  a  diet  containing  very  little  protein,  and 
as  such,  milk  was  recommended.  This  valuable 
food  still  forms  the  mainstay  in  this  disease. 

If  we  take  into  consideration  the  great  variety 
of  symptoms  met  with  in  nephritics,  it  is  at 
once  clear  that  one  and  the  same  diet  will  not 
fit  every  case.  Thus  a  patient  with  edematous 


DIET  IN  DISEASES  OF  THE  KIDNEYS  159 

swellings  all  over  and  chloride  of  sodium  reten- 
tion will  require  a  salt-free  diet  and  restriction  of 
fluid,  while  another  with  almost  natural  water 
and  chloride  of  sodium  excretion,  will  be  able  to 
take  fluids  and  a  moderate  amount  of  salt. 

With  regard  to  diet,  the  affections  of  the 
kidneys  will  have  to  be  divided  into  the  follow- 
ing groups: 

1.  Acute  conditions  (nephritis  acute),  includ- 
ing exacerbations  of  chronic  states. 

2.  Chronic  affections: 

(a)  parenchymatous  nephritis. 
(6)  interstitial  nephritis, 
(c)  congestive  nephritis. 

3.  Complications: 

(a)  Uremia;  (6)  Dropsy. 

1.  In  acute  nephritis  (sudden  onset  of  disease, 
edematous  swellings,  diminished  urinary  secre- 
tion, much  albumen  casts,  etc.)  including 
exacerbations  of  the  chronic  kidney  lesions  (which 
present  similar  symptoms),  the  diet  and  in 
fact  the  entire  plan  of  treatment  is  guided  by 
the  principle  of  rest.  Milk,  gruels,  and  mineral 
or  plain  water  are  given  in  quantities  of  about 
150.  cc  (5V)  every  2  hours  or  so.  If  cow's  milk 


160  LECTURES  ON  DIETETICS 

is  not  well  borne,  a  vegetable  milk  (prepared 
of  nuts  or  sweet  almonds)  may  be  given  instead. 
Meat  soups  (containing  extractive  material)  and 
foods  rich  in  protein  are  forbidden.  Lemonade 
and  fruit  juices  can  be  given.  The  work  of  the 
kidney  is  reduced  to  a  minimum  and  its  func- 
tion partially  replaced  by  other  eliminative 
organs  (skin  and  intestine).  With  this  object 
in  view,  the  diet  can  be  of  assistance.  Hot 
drinks  even  in  small  quantities,  like  lemonade  or 
weak  tea,  will  act  as  a  sudorific,  while  fruits 
(containing  organic  acids)  will  increase  the  intes- 
tinal activity.  As  soon  as  the  acute  symptoms 
begin  to  subside,  the  diet  should  be  increased. 
The  latter  also  applies  to  acute  conditions 
lasting  a  longer  time  (10  days,  2-3  weeks  etc.). 
Here  likewise  more  food  should  be  given.  The 
patients  are  fed  on  milk,  gruels,  porridges,  bread, 
2-3  eggs  (boiled  or  scrambled)  and  fruits.  As 
little  salt  and  seasoning  as  possible  should  be 
permitted  in  the  diet. 

2.  The  diet  in  chronic  affection  of  the  kidneys, 
(a)  Chronic  parenchymatous  nephritis  (face, 
pale  and  edematous,  urine  of  moderately  light 
specific  gravity  containing  albumen  and  casts.) 

This  forms  a  class  of  cases  in  which  a  great 


DIET  IN  DISEASES  OF  THE  KIDNEYS  161 

many  practitioners  prescribe  a  milk  diet  and 
keep  it  up  indefinitely.  While  milk  presents 
an  ideal  food  for  these  patients  and  may  be  used 
with  advantage  for  a  week  or  two  at  a  time,  it 
should  not  form  the  only  means  of  nourishment 
for  a  prolonged  time.  Although  the  kidneys  are 
given  more  rest  under  this  regime,  the  organism 
suffers  from  this  onesided  and  at  times  insuffi- 
cient alimentation.  The  anemia,  here  gener- 
ally present,  is  enhanced  and  thus  the  conditions 
are  unfavorable  for  the  recuperation  of  any  dis- 
eased organ.  The  consequence  is  that  the  kid- 
ney not  withstanding  its  diminished  activity, 
does  not  recover.  A  more  liberal  diet  although 
requiring  more  strenuous  work  from  the  kidney 
creates  a  more  healthful  state  of  the  individual 
and  gives  the  affected  organ  a  better  chance  for 
recovery. 

The  daily  diet  will  therefore  consist  of  the 
following : 

Milk  or  kumyss,  about  a  quart,  gruel  or 
porridge  about  one  pint  (given  in  two  portions), 
2-3  eggs  (soft  boiled,  scrambled  or  poached), 
tender  meat,  preferably  the  white  kinds  (about 
3-4  ounces),  bread  and  butter;  weak  tea  or 

weak  coffee  with  sugar;  light  vegetables   and 
11 


162  LECTURES  ON  DIETETICS 

fruits.  Table  salt  should  be  avoided,  and  the 
dishes  prepared  if  possible,  without  salt;  season- 
ing substances,  pepper,  onion,  mustard  and  the 
like,  should  likewise  be  avoided.  Meat  soups 
and  broths  should  be  forbidden.  The  amount  of 
fluid  including  that  contained  in  the  food,  should 
not  be  more  than  two  quarts  and  a  half  in  24 
hours. 

Great  variety  in  the  selection  and  preparation 
of  the  foods  is  very  desirable,  for  the  appetite 
of  the  nephritic  is  usually  poor  and  requires  as 
much  stimulation  as  possible.  The  patients 
should  be  encouraged  to  eat,  and  everything 
should  be  done  to  raise  the  nutritive  state  of  the 
organism. 

(6)  Chronic  interstitial  nephritis  (patient  usu- 
ally well  nourished  with  a  florid  complexion  and 
high  strung  temperament:  urine  pale,  abundant 
in  quantity,  of  a  diminished  specific  gravity, 
with  little  albumen  and  but  few  casts  and 
sufficient  sodium  chlorid  excretion;  the  blood 
pressure  is  usually  high). 

This  form  of  nephritis  is  frequently  encountered 
in  plethoric  and  stout  individuals.  Luxurious 
living,  high  tension  in  business  or  professional 
activities  and  diminished  mental  rest  as  well 


DIET  IN  DISEASES  OF  THE  KIDNEYS  163 

as  lessened  muscular  exercises  greatly  contribute 
toward  the  development  of  interstitial  nephritis. 
Tobacco  and  alcohol  are  here  also  contributory 
factors. 

The  dietary  regime  will  be  of  a  restricting 
type.  Simple  foods  in  moderate  quantities  with 
but  scanty  protein,  should  be  given.  Purin 
containing  aliments,  alcoholic  beverages  and 
spices  should  be  prohibited.  The  physician 
will  have  to  guard  the  patient  against  taking  too 
large  an  amount  of  food.  In  fact  reduction  in 
the  body  weight  is  in  this  class  of  cases  frequently 
beneficial.  The  daily  ration  may  consist  of 
white  meat  (chicken  or  fish)  5iiiss,  one  or  2 
eggs,  some  salt-free  bread  and  butter,  vegetables, 
fruits  and  1-2  glassfuls  of  milk.  Alcoholic 
beverages,  coffee,  meat  broths  should  be  for- 
bidden: while  alkaline  mineral  waters  and  a 
moderate  quantity  of  weak  tea  may  be  given. 

Occasionally  it  is  advisable  to  institute  one  or 
two  meat-free  days  weekly  and  also  to  prescribe 
a  very  small  breakfast  (^  roll  and  one  cup  of 
weak  tea  without  milk) .  Provided  the  quantity 
of  foods  taken  at  the  other  two  meals  is  not 
increased,  this  plan  of  alimentation  will  lead  to 
a  slight  reduction  in  weight.  Wherever  the 


164  LECTURES  ON  DIETETICS 

latter  appears  desirable,  this  regime  can  be 
applied  with  advantage. 

(c)  Congestive  nephritis;  (scanty  urine  of  high 
specific  gravity  containing  a  small  amount  of 
albumen,  without  any  or  but  very  few  casts). 

Congestive  nephritis  is  usually  due  to  grave 
disturbances  of  the  heart  leading  to  diminished 
pressure  in  the  renal  arteries  and  increased  pres- 
sure in  the  corresponding  veins.  The  treatment 
must  be  directed  toward  improving  the  general 
circulatory  system  and  the  diet  will  be  that 
adapted  for  the  special  heart  lesion. 

The  main  principle  is  to  select  a  diet  suitable 
for  rest  of  the  kidneys — as  little  protein  as 
possible,  no  irritating  substances,  a  small  amount 
of  fluid.  Karell's  diet  is  here  appropriate  for 
about  3-5  days.  Later,  especially  if  the  condi- 
tion improves,  the  diet  is  gradually  and  cau- 
tiously increased. 

3.  Complications.  — (a)  Uremia. — The  dimin- 
ution of  the  excretory  function  of  the  kidney 
leads — if  pronounced,  already  at  the  beginning 
of  the  disease,  otherwise  in  the  later  stages — to 
uremia.  The  latter  manifests  itself  when  pres- 
ent in  a  minor  degree,  by  slight  headaches, 
nausea  sometimes  accompanied  by  vomiting 


DIET  IN  DISEASES  OF  THE  KIDNEYS  165 

and  general  unneasiness.  When  the  excretory 
function  is  lacking  in  a  higher  degree,  it  leads 
to  loss  of  consciousness  and  also  convulsions. 
The  arterial  blood  pressure — usually  high  in 
nephritics — frequently  shows  a  further  increase; 
although  in  rare  instances  the  reverse  takes  place 
(bad  prognosis). 

The  diet  will  consist  of  milk  and  gruels  and 
fruit  juices,  5  to  7  ounces  every  2-3  hours. 
When  vomiting  exists  or  when  loss  of  conscious- 
ness be  present,  rectal  alimentation  must  be 
resorted  to.  Notwithstanding  the  existence  of 
edema,  a  5-6%  glucose  solution  can  be  given 
by  the  Murphy  Drip  through  the  rectum  in 
quantities  of  one  to  two  quarts  daily.  By  this 
means  it  is  occasionally  possible  to  stimulate  the 
kidneys  to  better  work,  in  such  a  manner  that 
the  obnoxious  substances  are  ultimately  removed, 
— leading  to  a  return  of  consciousness.  As 
soon  as  patient  is  able  to  take  food,  the  same  diet 
is  employed  as  in  acute  nephritis.  Provided 
there  is  a  further  improvement  alimentation  is 
gradually  increased  and  the  rules  laid  down  in 
chronic  kidney  disease  observed. 

(b)  Dropsy  (general  edematous  swelling,  ana- 
sarca,  ascites;  pleuritic  exudations)  frequently 


166  LECTURES  ON  DIETETICS 

appears  in  acute  nephritis  and  is  almost  always 
encountered  at  one  time  or  another,  during  the 
chronic  stage  of  renal  affections.  This  complica- 
tion requires  special  treatment  and  diet.  An 
exclusive  milk  diet  (l>^-2^  quarts  daily)  is 
frequently  found  beneficial,  the  urine  becoming 
more  abundant,  showing  less  albumen,  and  the 
swellings  gradually  disappearing.  The  general 
nutrition,  however,  cannot  improve  on  this 
insufficient  alimentation.  For  this  reason  this 
regime,  while  useful  for  a  short  period  of  time, 
cannot  be  employed  indefinitely. 

Widal  and  Strauss  have  conclusively  shown 
that  chloride  of  sodium  retention  which  is 
frequently  met  with  in  nephritis  leads  to  edema. 
This  discovery  gave  origin  to  a  new  mode  of 
diet  appropriate  for  these  cases,  namely  the 
salt-free  diet.  Restriction  of  fluids  and  of  chlor- 
ide of  sodium  is  most  important.  The  diet 
consists  of  bread,  milk,  eggs,  arrowroot,  rice, 
vegetables;  everything  prepared  without  salt. 
Fish,  poultry  or  meat  may  be  added,  and  milk 
(if  not  desired)  entirely  omitted  from  the  bill- 
of-fare.  The  quantity  of  meat  should  however, 
not  exceed  Y±  of  a  pound  a  day.  Fruits  should 
be  given  in  considerable  quantities,  while  spices 


DIET  IN  DISEASES  OF  THE  KIDNEYS  167 

and  meat  soups,  likewise  alcoholic  beverages, 
should  be  entirely  forbidden.  The  salt-free  diet 
regime  has  been  generally  accepted  and  is 
employed  with  great  benefit. 

Another  mode  of  dietary  regime  for  dropsy  has 
been  suggested  by  Kakowski.1  This  eminent 
clinician  gives  his  patients  3-5  pounds  of  squash 
daily  divided  into  3  portions,  prepared  with 
milk  or  cream  or  rice  soup  and  butter.  The 
squash  is  prepared  as  follows: 

Raw  squash,  in  quantities  of  3-5  pounds,  is 
cut  into  small  pieces  and  placed  into  a  pot,  a 
small  quantity  of  water,  enough  to  cover  the 
bottom,  is  added  and  the  whole  mass  stirred. 
The  pot  is  now  left  boiling  over  a  low  fire  for 
two  hours,  and  the  contents  are  frequently 
stirred.  The  squash  mush  is  then  mixed  with 
some  butter  and  milk-soup  (usually  rice  soup) 
and  is  ready  for  use.  Instead  of  water  the 
squash  may  be  prepared  with  cream,  which  gives 
it  a  better  flavor  and  makes  it  more  nutritious. 

Kakowski  had  excellent  results  from  this 
exclusive  squash  regime.  He  considers  the 
squash  as  the  best  natural  diuretic,  increasing 

1  A.  Kakowski:  "Die  Kdrbisbehandlung  der  Odeme."  Zeitschr.  f. 
phys.  und  diatetische  Therapie,  Juni  and  Juli,  1914,  Bd.  xviii,  h.  6,  7, 


168  LECTURES  ON  DIETETICS 

the  secretory  function  of  the  kidney  without 
having  any  slight  irritative  effect  on  this  organ. 

In  conjunction  with  Dr.  N.  Stadtmiiller  I 
have  employed  squash  and  also  musk  melons, 
watermelons  and  cucumbers  in  cases  of  dropsy. 
While  we  did  not  see  as  striking  results  as 
described  by  Kakowski,  we,  nevertheless,  had 
the  impression  that  this  group  of  fruits  (cucur- 
bitse)  acts  beneficially  on  the  kidney  function 
and  deserves  recommendation.  The  squash  we 
gave  as  prescribed  by  Kakowski.  Musk  and 
watermelons,  we  employed  raw  (about  2  pounds 
daily),  taken  in  conjunction  with  a  salt-free  diet. 
The  cucumbers  were  given  as  a  vegetable,  boiled 
in  milk,  about  a  pound  daily,  also  in  conjunc- 
tion with  a  salt-free  diet. 

Squash,  melons  and  cucumbers  may  be  admin- 
istered with  advantage  not  only  in  cases  of 
dropsy,  but  in  all  instances  of  kidney  derange- 
ment. The  beneficial  action  of  the  cucurbitacese 
may  be  explained  by  their  richness  in  potassium 
salts  while  containing  but  little  chloride  of 
sodium,  and  also  by  their  mild  aperient  qualities. 


LECTURE  XII 
DIET  REGIMES 

In  my  previous  lectures  I  have  given  the 
principles  of  diet  in  health  and  disease.  Based 
upon  them  every  physician  will  be  enabled  to 
arrange  a  diet  suitable  to  the  requirement  of 
each  case.  In  the  following,  however,  I  thought 
it  best  to  describe  briefly  several  important 
standard  diet  regimes,  which  can  be  used  to 
advantage  for  shorter  or  longer  periods  of  time 
in  appropriate  cases  but  never  indefinitely. 

SUPERALIMENTATION  REGIME 

Breakfast,  7:30-8  A.  M.:  Oatmeal  with  butter,  or 
farina  with  cream,  2  eggs,  bread  (1-2  rolls)  and  butter, 
one  cup  of  coffee  (half  milk)  with  sugar. 

10:30:  One  cupful  of  milk  with  one  raw  egg  beaten  up 
in  it;  bread  and  butter. 

Luncheon,  12 :30-1 :  One  cup  of  bouillon  with  one  egg, 
1-2  rolls,  butter,  tender  meat,  mashed  or  baked  potato; 
weak  tea  (half  milk)  with  sugar. 

3:30:  Same  as  10:30  A.  M. 

Dinner,  6:30-7:  Cream  soup;  fish;  tender  meat, 
potato,  peas  or  beans;  bread  and  butter,  stewed  fruit; 
small  cup  of  coffee. 

169 


170  LECTURES  ON  DIETETICS 

9:30:  Kumyss  and  crackers  and  butter. 
The  quantity  of  butter  to  be  used  daily  should  be 
about  a  quarter  of  a  pound. 

This  superalimentary  regime  can  be  kept 
up  for  a  long  period  of  time  and  is  suitable  in 
conditions  in  which  a  building  up  of  the  system 
is  required. 

(a)   PROTEID— FAT  REGIME 

Breakfast:  One  cup  of  tea  (no  sugar,  no  milk), 
one  egg  with  butter,  one  portion  of  ham,  or  bacon. 

Dinner:  One  cup  of  bouillon  (5vii),  200  gm.  (5vii) 
meat  or  fish  broiled,  2  eggs,  hard  boiled,  lettuce,  spinach 
or  asparagus,  one  cup  of  tea. 

Supper:  Fried  eggs  (3)  and  bacon,  or  fried  fish  with 
hard  boiled  eggs  or  a  portion  of  cold  meat,  150  gm.(5  v). 

This  diet  is  suitable  for  diabetes  mellitus  and 
for  reducing  corpulency.  Elderly  persons  and 
patients  with  heart  and  kidney  lesions  do  not 
bear  well  this  rigorous  regime.  It  is  then  neces- 
sary to  add  some  more  vegetables  (green  peas, 
beans)  and  a  small  quantity  of  milk  or  cream  to 
the  above  bill  of  fare. 

(6)  Banting's  Regime. — Breakfast:  Meat  (beef,  mut- 
ton, kidneys,  fish  or  ham),  120-150  gm.  (5iv-v);  one 
big  cup  of  tea  (without  milk  or  sugar);  zwieback  or 
toasted  bread  (without  butter),  30  gm.  (5ii)« 


DIET  REGIMES  171 

Dinner:  Pish  (excepting  salmon)  or  meat  (excepting 
pork),  150-180  gm.  (5v-vi);  vegetables  (excepting 
potato);  toasted  bread,  30  gm.  (5i);  (red  wine  or 
Madeira,  2-3  glassfuls  permissible;  champagne  or  ale 
forbidden). 

During  the  afternoon:  Fruit,  60-90  gm.  (5ii-iii); 
1-2  zwieback;  one  cup  of  tea  without  milk  or  sugar. 

Supper:  Meat  or  fish,  90-120  gm.  (5iii-iv);  grog  with- 
out sugar  or  1-2  glassfuls  of  claret. 

Notwithstanding  the  apparent  great  amount 
of  foods  this  bill  of  fare  contains,  it  furnishes  but 
1100  calories  per  day.  The  Banting  regime  is 
used  principally  as  an  anti-fat  diet.  A  great 
many  patients,  however,  cannot  stand  it  and 
frequently  collapse  after  using  it  a  few  days. 

Ebstein  improved  the  Banting  regime  and 
modified  it  as  follows: 

(c)  Ebstein-Banting  Regime. — Breakfast:  Tea,  one 
cup,  without  milk  or  sugar;  bread,  50  gm.  (5i%)»  plenty 
of  butter. 

Dinner:  Soup,  one  plate;  meat,  120-180  gm.  (5iv-vi) 
fried  or  boiled  with  rich  gravy;  beans,  peas  and  cabbage; 
(no  potatoes,  no  beets) ;  salad;  raw  or  baked  fruit  without 
sugar;  mild  white  wine,  1-2  glassfuls. 

In  the  afternoon  same  as  at  breakfast. 

Supper:  One  cup  of  tea  without  sugar  or  milk;  one 
egg;  fried  meat  or  ham,  smoked  fish;  bread  about  30  gm. 


172  LECTURES  ON  DIETETICS 

(5i)  well  buttered;  a  small  portion  of  cheese,  and  fresh 
fruit. 

(d)  Oertel -Banting  Regime. — Breakfast:  Wheaten, 
bread,  30  gm.  (5i);  coffee.  120  gm.  (5iv),  with  milk, 
30  gm.  (50;  sugar,  5  gm.  (3i) ;  2  soft-boiled  eggs  (90  gm. 
or  5iii)- 

At  11  A.  M.:  Wine,  bouillon,  or  water,  100  gm.  (5iiiss); 
cold  meat,  50  gm.  (5 if);  rye  bread,  20  gm.  (5f)- 

Dinner:  Wine,  250  gm.  (5viii|);  fried  beef,  150  gm. 
(5v);  salad,  50  gm.  (5 if);  pudding,  100  gm.  (5i"i); 
bread,  30  gm.  (5i);  fruit,  100  gm.  (5"ii). 

4  P.  M.:  Coffee,  120  gm.  (5iv);  milk,  30  gm.  (5i); 
sugar,  5  gm.  (3i). 

Supper:  Wine  or  water,  250  gm.  (Sviiif);  caviar, 
12  gm.  (3iii);  venison,  150  gm.  (5v);  cheese,  15  gm. 
(5ss);  rye  bread,  20  gm.  (3v);  fruit,  100  gm.  (5 "if). 

VEGETARIAN  DIET  REGIME 

(a)  Schroth's  Dry  Diet. — Patient  is  allowed  to  eat  dry 
well-baked  rolls,  2-3  days  old.  At  noon-time  he  takes  a 
soup,  made  out  of  water,  rice,  farina  or  broken  up  rolls 
with  the  addition  of  some  butter  or  salt.  As  a  drink 
patient  is  given  oatmeal  gruel  and  is  told  to  sip  it  slowly, 
when  real  thirsty. 

This  diet  is  maintained  for  the  first  week.  During  the 
second  week  a  glassful  of  wine  mixed  with  hah*  a  glassful 
of  water  and  some  sugar  is  given  warm  in  the  afternoon, 
while  the  rest  of  the  diet  remains  unchanged. 

During  the  third  week  patient  lives  on  the  same  diet, 
but  leaves  off  the  wine  every  alternate  day. 


DIET  REGIMES  173 

Schroth's  diet  may  be  advantageously  used 
in  edematous  swellings  and  ascites,  also  in 
arteriosclerosis,  omitting  the  wine,  however,  for 
a  period  of  5  days  or  a  week.  Being  a  diet 
much  deficient  in  calories  and  nutritive  material 
it  must  be  employed  with  great  care  and  for 
short  periods  of  time  only. 

Very  similar  to  Schroth's  diet  is 

(6)  Bulkley's  Rice,  Bread,  Butter  and  Water 
Regime.1 — The  patient  lives  exclusively  on  rice,  bread, 
butter  and  water. 

The  rice  should  be  thoroughly  cooked  with  water 
(not  with  milk).  Generally  it  is  better  to  have  it  dried 
out  somewhat,  so  as  to  be  flaky,  by  leaving  it  uncovered 
on  the  fire  for  a  while.  The  rice  is  freshly  prepared  with 
abundance  of  butter  and  salt.  It  should  be  eaten  slowly 
with  a  fork  and  be  perfectly  masticated.  The  bread  and 
butter  should  also  be  well-chewed,  to  secure  the  full 
action  of  the  saliva.  Water,  hot  or  cold,  but  not  iced, 
is  to  be  taken  freely,  but  not  to  wash  down  the  food  in 
the  mouth. 

This  diet  should  be  kept  up  for  5  days,  when 
an  ordinary  mixed  diet  is  resumed. 

1L.  D.  Bulkley:  Personal  Experience  with  a  Very  Restricted  Diet 
(Rice)  in  Acute  Inflammatory  Diseases  of  the  Skin.  Med.  Record, 
Jan.,  28,  1911.  Abo  Bulkley,  "Diet  and  Hygiene  in  Diseases  of  the 
Skin,"  Hoeber,  N.  Y ,  1913. 


174  LECTURES  ON  DIETETICS 

This  rice,  bread,  butter,  and  water  diet  is 
useful  in  acute  inflammatory  conditions  of  the 
skin  like  eczema,  erythema,  and  principally 
itching. 

(c)  Hoffmann's  Regime. l — Hoffmann's  regime  is  a 
coarse  vegetable  diet  consisting  of  brown  bread,  Graham 
bread,  butter,  potatoes,  and  all  kinds  of  vegetables  con- 
taining much  cellulose,  principally  cabbage;  beets,  beans, 
mushrooms,  salads;  peas,  lentils  (not  pureed);  plenty  of 
fruits. 

Hoffmann's  regime  is  best  adapted  for  obsti- 
nate neuralgias  of  unknown  origin  and  for 
obesity  accompanied  with  constipation.  It  may 
be  kept  up  for  a  period  of  two  weeks.  Then  it 
must  be  changed  into  a  diet  of  greater  nutritive 
value. 

MILK  REGIME 

Milk  is  a  complete  nourishment  and  may  be  given  up 
to  3-4  quarts  daily.  The  patient  will  best  take  about  a 
pint  of  milk  every  2  hours. 

This  diet  is  indicated  in  irritative  conditions 
of  the  digestive  tract  (ulcus  ventriculi;  chron. 
enteritis;  cirrhosis  hepatis,  and  in  affections  of 
the  kidneys). 

1  A.  Hoffmann:  Leyden's  Handbuch  der  Ernahrungstherapie,  Bd.  i, 
p.  568;  Leipzig,  1896. 


DIET  REGIMES  175 

Karell1  highly  recommended  the  milk  diet. 
He  gave  during  the  first  week  200  cc.  (5vii)  of 
skimmed  milk  four  times  daily.  If  there  were 
no  bowel  disturbances  he  increased  the  quantity 
during  the  second  week  to  one  quart  and  a  hah* 
daily. 

KareH's  scanty  milk  diet  is  useful  in  severe 
neuralgias,  in  affections  of  the  heart  and  kidneys 
accompanied  with  edematous  swellings  or  ascites. 

SOUP  DIET 

Soup  diet  or  liquid  diet  consists  of  mixtures  of  nourish- 
ment given  in  fluid  form.  This  is  the  standard  diet  for 
all  acute  febrile  diseases,  and  for  chronic  conditions  for 
periods  of  time.  It  can  be  varied  according  to  the 
requirement  of  the  case.  Eight  to  10  ounces  of  gruels 
(oatmeal, — barley, — rice  or  pea — or  lentil-flour)  alone  or 
mixed  with  hah*  milk  every  2  hours  can  be  employed  in 
most  instances.  When  it  is  necessary  to  supply  a 
sufficient  nutrition,  raw  eggs,  lactose,  or  butter  may  be 
added  and  should  be  thoroughly  mixed  with  the  above 
foods.  Thus  1-2  eggs  may  be  mixed  in  a  cupful  of  milk, 
or  gruel,  or  bouillon;  or  lactose  5ss~5i>  or  butter  5"i 
added  to  milk  or  gruels  with  or  without  egg.  Instead  of 
milk,  kumyss  or  zoolak  or  buttermilk  may  be  given  for  a 
change.  Clambroth  and  oyster-stew  in  milk,  without 

1  Karell:  Arch,  gfenerales,  1866. 


176  LECTURES  ON  DIETETICS 

the  oysters,  further  enlarge  the  bill  of  fare.  Milk, 
flavored  with  tea,  cocoa,  or  coffee;  lemonade,  orangeade, 
are  also  useful  in  increasing  the  variety  of  the  monoto- 
nous diet. 


FLUID  DIET  WITHOUT  NUTRITIVE  VALUE 

Breakfast,  8  A.  M.  :  Tea  or  coffee,  1-2  cups,  250-500  cc. 
Lunch,  12:  Bouillon  1-2  cups,  250-500  cc. 
4  P.  M.:  Tea  or  coffee,  1-2  cups. 
Supper,  8  P.  M.  :  Bouillon,  1-2  cups. 

Two  quarts  of  plain  water  or  Apollinaris  or  Vichy 
should  be  consumed  in  addition  in  every  24  hours. 


FLUID  DIET  WITH  LOW  NUTRITIVE  VALUE 

Calories 
8  A.  M.:  Tea  or    coffee,    250-500    with 

one  teaspoonful  of  sugar 16 

Lunch,  12:  Thin  barley  gruel  (one  tablespoonful) 

300  cc 50 

4  P.  M.:       Bouillon,  250-500  c.c. 

8  P.  M.:       Lemonade,     250-500    cc.     with    one 

tablespoonful  of  sugar 60 


126 

Two  quarts  of  plain  water  or  Apollinaris  or  Vichy 
should  be  consumed  in  addition  in  every  24  hours. 


DIET  REGIMES 


177 


MEDIUM  FLUID   DIET  (HALF  RATION) 

Calories 

8  A.  M.:  Milk,  300  c.c 202 

10  A.  M.:  Milk  and  strained  barley   water    (aa) 

300  c.c 160 

12  noon:     Bouillon  300  cc.  with  the  white  of  2 

eggs 30 

2  P.  M.:      Lemonade  300  cc.,  with  2  tablespoon- 

fuls  of  sugar 120 

4 P. M.:        Milk,  300  cc 202 

6  P.M.:       Same  as  12 30 

8  P.  M.:       Whey,  300  cc 60 

10  p.  M.:     Same  as  2  P.  M..  120 


924 
One  quart  of  water  should  be  taken  in  addition  in 

24  hours. 

FULL  PLUTO  DIET  (FULL  RATION) 

Calories 

8  A.  M.:  Milk  (200  cc.)  with  coffee  (100 

cc.)  and  sugar  2  teaspoonfuls 160 

10  A.  M.      Bouillon  and  one  egg 82 

12  A.  M.      Milk    (200   cc.),    cream    (50  cc.)  and 

cereal  (50  c.c.) 426 

2  P.  M.       Same  as  8  A.  M 160 

4  P.  M.       Milk  (250),  cream  (50) 206 

6  p.  M.       Milk  (200)  tea  (50),  cream  (50),  sugar 

2  teaspoonfuls 328 

8  P.  M.       Milk  (200),  cream  (50),  cereal  (50). ...  426 

10  P.M.;     Milk  (300)..  192 


12 


2,070 


178  LECTURES  ON  DIETETICS 

DIET  FOR  CONVALESCENTS 

Breakfast,  8  A.  M.:  Soft  boiled  or  poached  eggs  (2); 
toast  and  butter,  coffee  with  milk  and  sugar. 

10:30  A.  M.:  Egg  nog;  crackers  and  butter. 

Lunch,  12:30  p.  M.  :  Cream  soup  or  meat  soup;  white 
bread  and  butter;  tender  meat;  mashed  or  baked 
potatoes;  spinach  or  cauliflower;  custard  or  tapioca 
pudding. 

3:30  P.  M.:  Egg  nog;  crackers  and  butter. 

6:30  P.  M.:  Fish,  or  oysters;  scrambled  eggs  or  an 
omelette;  toast  and  butter;  rice  or  tapioca  pudding; 
cup  of  weak  tea  with  sugar  and  milk. 

9 :30  P.  M.  :  One  glassful  of  milk  or  kumyss  and  crackers 
and  butter. 


PURIN-FREE  DIET1 

Breakfast:  Fruit  (apple,  banana,  pear,  grapefruit  or 
orange);  cereal  (oatmeal  or  farina)  with  cream  or  butter; 
one  egg;  bread  and  butter;  milk. 

Dinner:  1-2  eggs;  mashed  or  baked  potatoes  with 
butter;  green  vegetables  (string  beans,  cauliflower, 
Brussels  sprouts),  rice  or  spaghetti;  baked  apple;  milk. 

Supper:  Cereal  (rice  or  oatmeal  or  farina)  with  butter; 
cheese,  bread  and  butter;  stewed  fruits;  tapioca  or  rice; 
milk. 

1  This  diet  is  useful  for  short  intervals  of  time  in  high  blood  pressure. 


DIET  REGIMES 


179 


DIET  FOR  INTESTINAL  PUTREFACTION 


Breakfast: 


Fruit:  apple,  banana,  pear,  grapefruit,  orange 
Cereal:  oatmeal,  farina,  shredded  wheat,  with  milk  or 
cream 

Bread  and  butter 
Tea 


Dinner: 


Soup:  vegetable 

2  eggs:  soft  boiled,  scrambled 

Potatoes:  rice  or  spaghetti 

Baked  apple 

Coffee  with  milk 


Supper: 


Rice  and  milk 

Cereal:  oatmeal,  farina,  shredded  wheat,  with  butter 

Cheese 

Bread  and  butter 

Stewed  fruits 


VEGETABLE  MILK  DIET 

Vegetable  milk,  as  recommended  by  Fischer1, 
is  obtained  from  sweet  almonds  or  Para-nuts,  in 
the  following  manner.  Hah*  a  pound  of  sweet 
almonds  or  Para-nuts  (freed  from  the  shell  and 
skin)  are  grated,  then  pounded  in  a  mortar  with 
a  piston  under  the  addition  of  small  quantities  of 
cold  water  until  the  amount  reaches  one  quart. 
Rub  the  mixture  thoroughly  until  there  is  a 
perfect  emulsion.  Put  the  mixture  on  ice  for 
2  hours,  then  strain  over  a  cheese  cloth.  It 


1  A.  Fischer:  Arch.  f.  Verdauungskrankh.,  Bd.  xx,  h.  2. 


180 


LECTURES  ON  DIETETICS 


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e  c  o 

in 


88 


o_«oqo 
t~«;t^rC 


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X  o  ro  ro 


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should  be  used  freshly  prepared 
and  kept  on  ice.  Every  day  a 
fresh  supply  must  be  made. 

The  above  table  shows  that 
the  vegetable  milk  contains 
about  as  much  albumen  as 
cow's  milk,  but  is  richer  in 
fat  and  poorer  in  carbohy- 
drates. It  also  contains  less 
chlorides  than  cow's  milk. 
These  qualities  make  the  vege- 
table milk  a  valuable  element 
in  gastric  hyperacidity  and  in 
kidney  and  heart  lesions.  It 
can  be  given  in  quantities  of 
one  quart  to  one  and  one  half 
quarts  daily,  in  addition  to 
other  foods,  or  alone  up  to 
three  quarts  in  24  hours. 

DIETS   FOR  PATIENTS  ENTERING 
THE  HOSPITAL 

With  regard  to  diet  we  can 
divide  patients  entering  a  hos- 
pital into  the  following  groups : 
(1)  patients  without  fever 


DIET  REGIMES  181 

suffering  from  constitutional,  nervous,  and  skin 
lesions  requiring,  medical  aid  and  likewise 
patients  without  fever  with  some  special  affec- 
tions outside  of  the  digestive  tract,  as  for 
instance,  tumors  of  the  knee,  dermoid  cysts, 
lipomata,  etc.,  needing  surgical  help;  (2)  patients 
without  fever  suffering  from  the  digestive  tract; 
(3)  medical  or  surgical;  cases  accompanied  by 
fever. 

In  group  1  a  full  diet  can  be  given. 

In  group  2  a  soft  diet  is  best. 

In  group  3  a  liquid  diet  should  be  instituted. 

In  the  following  I  give  the  3  forms  of  diet: 
(1)  full  diet;  (2)Soft  diet,  (3)  fluid  diet,  as  used  in 
the  Lenox  Hill  Hospital,  New  York,  which  are 
very  appropriate  for  patients  entering  the  hospi- 
tal, as  preliminary  modes  of  nutrition. 


182  LECTURES  ON  DIETETICS 

DlETABY   FOB   PATIENTS   ENTERING   HOSPITALS 


Breakfast 

Second  break- 
fast 

Dinner 

Supper 

Form  I 

Bread,  4  os. 

Milk,  %  pt. 

Soup,  «  pt. 

Cold  meat, 

4  os. 

Full  diet  ... 

Coffee  with 

Zwieback,  2  or 

Meat,  6  os. 

Bread,  4  os. 

milk,  *i  pt. 

or     crackers, 

Potatoes,  6  os. 

Butter,  H  os. 

Sugar,  H  01. 

3 

Vegetables,     4 

Tea  with  milk 

Butter 

os.  on  Sunday 

Jipt. 

Butter,  K  01. 

Tuesday 

Stewed  fruit  on 

Oatmeal   or 

Wednesday 

certain  days 

farina  or  force, 

Thursday 

Eggs  instead  of 

4  os. 

Saturday 

meat 

Eggs,  soft  boil- 

Pudding  or 

ed 

stewed     fruit 

on  Friday  also 

fish 

Form  II 

Soft  diet.... 

Oatmeal    or 

Milk,  >i  pt. 

Eggs,   soft 

Eggs,   soft 

farina  or  rice 

Zwieback,  2 

boiled,  3 

boiled,  3 

with  milk, 

Crackers,  3 

Soup  with  far- 

Rice with  milk, 

10  os. 

Butter 

ina,     rice    or 

H  pt. 

Coffee  or  cocoa 

hominy,  J--J 

Crackers,  3 

with  milk,  >a 

Pt- 

Butter,  M  os. 

pt. 

Crackers 

Fruit  jelly 

Crackers,  1  os. 

Butter 

Butter,  H  os. 

Afternoon 

Lunch 

* 

Milk.  X  pt. 

Zwieback,  2 

Crackers,  3 

Form  III 

Fluid  diet.  .  . 

Milk,  or  coffee, 

Milk,  fi  pt. 

Beef     tea,     or 

Milk  or  tea,  or 

or  cocoa  with 

Zwieback,  2  or 

gruel     broth, 

cocoa     with 

milk,  %  pt. 

crackers,  2 

X.  Pt. 

milk.  >i  pt. 

Eggs,  raw,  1 

Eggs,  raw,  1 

Eggs,  raw,  1 

Before  any  operation  is  undertaken  the  ques- 
tion arises  whether  the  body  is  in  a  fit  condition 
to  stand  the  operation.  In  high  degrees  of 
subnutrition  and  inanition  it  is  sometimes  better 
to  delay  the  operation,  if  feasible,  until  a  better 
state  of  general  nutrition  can  be  accomplished. 
If  the  nature  of  the  disease  excludes  such  a  possi- 
bility then  filling  up  of  the  system  with  water, 
will  be  of  great  assistance. 

Any  kind  of  general  anesthesia  (chloroform  or 
ether)  requires  some  preparatory  dietetic  regime. 
Usually  it  is  best  to  have  the  patient  on  a  light 
diet  (milk,  cereals  and  light  vegetables,  a  few 
eggs,  very  little  meat,  bread  and  butter,  soups, 
stewed  fruits)  the  day  before  the  operation. 
A  mild  cathartic  the  night  previous  to  operation 
is,  likewise,  appropriate,  although  not  absolutely 
essential.  If  the  operation  is  done  in  the  early 
morning  it  is  best  to  have  the  patient  in  the 
fasting  condition.  If  later  in  the  day,  a  light 
breakfast  consisting  of  tea  and  toast,  is  advisable. 

183 


184  LECTURES  ON  DIETETICS 

When  the  operation  is  in  the  afternoon,  then  an 
early  luncheon  of  a  cup  of  bouillon  and  crackers 
may  also  be  given. 

The  reason  why  no  bigger  meal  is  allowed  is 
the.  tendency  to  vomit  on  account  of  the 
anesthesia. 

Following  the  anesthesia  no  food  is  given  until 
the  following  day.  For  thirst  small  pieces  of  ice 
can  be  kept  in  mouth,  or  the  latter  may  be 
frequently  washed  with  cool  plain  water  or 
with  mineral  water.  A  Murphy  drip  per  rectum 
of  saline  or  saline  with  coffee  will  also  be  of  help. 

A  day  after  the  operation  the  diet  will  depend 
upon  (1)  the  state  of  the  stomach  as  influenced  by 
the  anesthesia  and  (2)  upon  the  nature  of  and  the 
organ  on  which,  the  operation  was  performed. 

THE  DIET  AS  INFLUENCED  BY  THE  ANESTHESIA 

The  effect  of  the  anesthetic  remedy  upon  the 
stomach  varies  in  different  individuals.  Some 
awake  and  show  no  ill  effects.  In  such  patients 
the  anesthesia  as  such  will  hardly  influence  the 
dietary  regime.  In  others  there  is  nausea  and 
vomiting  extending  for  a  number  of  days.  Here 
very  little  of  the  finest  nourishment  (egg  albumin 
water,  barley  water,  mutton  broth,  clam  broth, 
kumyss)  will  be  given  every  two  to  three  hours 


THE  DIET  IN  OPERATIVE  CASES        185 

until  there  is  a  decided  amelioration  of  the  gastric 
irritability,  when  more  substantial  foods  can  be 
given.  The  diet  should  always  be  gradually  and 
cautiously  changed  and  never  increased  too 
abruptly. 

THE   DIET   AS   INFLUENCED   BY   THE  NATURE  OF  THE 
OPERATION,  AND  THE  ORGAN  THE  LATTER  INVOLVES 

A  small  operation  like  the  removal  of  a  der- 
moid  cyst  or  lipoma  of  the  skin  will  require  no 
dietetic  change  and  patient  will  be  able  to  eat 
as  usual.  A  major  operation,  however,  no  mat- 
ter on  what  organ  influences  the  state  of  the 
whole  organism  inclusive  of  the  digestive  tract. 
There  is  usually  some  suffering  present,  while 
at  times  a  rise  of  temperature  exists.  A  light 
liquid  diet  will  be  appropriate  for  the  first  2-4  days. 
Thereafter  semiliquid  and  solid  food  can  be 
added. 

We  will  also  have  to  differentiate  between  oper- 
ations of  organs  outside  the  sphere  of  the  digestive 
apparatus  and  those  of  the  alimentary  tract. 

The  operations  outside  of  the  digestive  tract 
influence  the  diet  merely  in  a  general  way, 
depending  upon  the  condition  of  the  stomach 
and  the  general  state  of  the  organism  as  men- 
tioned above. 


186  LECTURES  ON  DIETETICS 

The  operations  on  the  alimentary  tract  require 
special  attention  with  regard  to  diet.  For  here 
the  food  or  its  products  have  to  pass  over  the 
operated  area.  The  dietary  regime  will  pay 
attention  to  favor  the  healing  process  as  much 
as  possible  and  to  introduce  sufficient  food  when 
feasible. 

In  operations  upon  the  esophagus  and  also 
the  stomach,  rectal  alimentation  and  still 
better  duodenal  alimentation  can  be  resorted 
to,  if  necessary.  Provided  the  patient  is  in 
good  nutritive  condition,  he  can  be  left  for  2-3 
days  without  food.  Small  amounts,  1-2  table- 
spoonfuls,  of  egg  albumen  water,  alternating 
with  the  same  quantity  of  barley  or  oatmeal  or 
rice  water,  are  given  every  hour  or  two  during 
the  day,  while  1-2  quarts  of  saline  or  of  a  5  per  cent 
glucose  solution  are  injected  daily  into  the 
rectum  by  the  Murphy  drip. 

On  the  3rd  day  of  the  operation  milk  and  barley 
water  mixed  (half  and  half)  is  added  to  the  above 
in  the  same  quantities.  On  the  fourth  day 
instead  of  one  ounce,  two  ounces  are  given  of  the 
same  nutritive  material.  On  the  5th  day  milk 
and  mutton  broth  and  gruels  with  milk  are  given 
every  two  hours  in  three  ounce  quantities.  On 


THE  DIET  IN  OPERATIVE  CASES        187 

the  sixth  day  4-5  ounces  of  the  above  with  the 
addition  of  one  raw  egg  in  bouillon  are  given 
every  two  hours.  Thereafter  the  diet  is  further 
increased  by  giving  every  day  an  addition  of  one 
ounce  more  every  two  hours  and  likewise  one 
egg  more  every  day,  so  that  on  the  7th  day 
7  ounces  and  two  eggs,  on  the  8th  day  8  ounces 
and  three  eggs,  on  the  9th  day  9  ounces  and  4 
eggs,  and  the  10th  day  10  ounces  and  5  eggs  are 
employed.  During  these  four  days  the  diet  is 
also  increased  step  by  step  in  consistency. 
Thus,  first  strained  gruels,  and  strictly  raw  eggs, 
beaten  up  in  milk  or  bouillon  are  administered; 
later  on  farina  in  the  milk,  coddled  eggs,  still 
later  crackers  and  butter,  mashed  potatoes  are 
added.  On  the  llth  day,  poached  eggs  on 
toast  are  added  and  chicken  with  baked  potatoes 
are  given  at  luncheon.  Soup  with  vermicelli, 
mashed  vegetables  and  stewed  fruits  are  then 
also  employed.  From  the  12th  day  on  it  is  well 
to  arrange  for  three  larger  meals  and  two  addi- 
tional smaller  meals,  the  latter  to  consist-of  milk 
or  egg  nogg  and  crackers  and  butter  or  toast  and 
butter,  while  the  larger  meals  resemble  more 
the  ordinary  meals. 

Coarse  foods  (like  salads,  raw  apples,  sausages) 


188  LECTURES  ON  DIETETICS 

will  be  avoided  for  a  long  time,  especially  after 
operations  upon  the'gastro-intestinal  canal  proper. 

It  is  self  understood  that  the  increase  in  the 
bill  of  fare  will  take  place,  as  stated  above, 
merely  when  the  patient  shows  no  ill  effect  from 
the  diet,  otherwise  the  nutrition  can  not  be 
increased,  and  in  some  instances  may  have  to  be 
decreased  for  a  period  of  time.  As  soon  as  the 
patient's  digestion  improves  the  increase  in  the 
diet  is  again  resumed. 

In  operations  upon  the  colon  and  the  rectum 
it  will  be  necessary  to  arrange  a  diet  which 
contains  very  little  undigestible  residue.  This 
serves  to  diminish  the  amount  of  fecal  matter, 
and  in  this  way  favor  the  healing  process  in  the 
colon.  The  diet  consists  of  eggs  beaten  up  in 
bouillon,  tender  meat,  cream,  tea  with  sugar, 
ice  cream;  in  plastic  operations  between  vagina 
and  the  rectum,  it  is  sometimes  necessary  to 
keep  up  artificial  constipation  for  a  week  or  so 
by  instituting  the  above  diet  and  administering 
opiates,  at  the  same  time.  As  soon  as  the 
healing  has  taken  place,  there  should  be  a  grad- 
ual return  to  the  customary  foods. 


SUBCUTANEOUS  ALIMENTATION 

By  subcutaneous  alimentation  is  understood 
a  method  of  nutrition  by  which  nutriment  is 
injected  under  the  skin.  In  this  way  the  alimen- 
tation is  incorporated  into  the  body  without 
coming  into  contact  with  the  digestive  appara- 
tus. This  mode  of  nutrition  has  the  great 
advantage  that  it  is  feasible  with  any  lesion  of 
the  digestive  tract,  but  it  has  the  disadvantage 
that  the  alimentation  escapes  the  action  of  every 
part  of  the  digestive  apparatus.  As  the  entire 
process  of  nutrition  takes  place  outside  of  the 
digestive  tract,  all  the  machinery  which  the 
organism  possesses  for  the  act  of  digestion  is 
ignored.  It  is  thus  seen  at  a  glance  that  this 
mode  of  nutrition  is  an  unnatural  one,  and  is  to 
be  employed  only  in  extreme  cases  when  every 
other  method  fails. 

Subcutaneous   alimentation   was   first   intro- 

189 


190  LECTURES  ON  DIETETICS 

duced  to  the  profession  by  Menzel  and  Perso,1 
who  experimentally  injected  solutions  of  milk 
and  sugar  subcutaneously  into  animals,  and 
found  that  absorption  took  place.  The  same 
clinicians  have  also  given  oil  subcutaneously  to 
patients.  Although  this  method  of  nutrition 
has  been  practiced  off  and  on  by  Karst,  Whi taker, 
Pick,  Carter,  and  Koll,  von  Leube2  must  be 
given  credit  for  having  improved  and  promul- 
gated it.  This  great  clinician  noticed  that  injec- 
tions of  camphor  oil  were  frequently  given  in 
various  ailments  without  any  detriment  to  the 
patient,  and  that  oil  could  therefore  be  incorpor- 
ated into  the  body  subcutaneously  without 
causing  any  obnoxious  consequences.  The  same 
substance  may  therefore  be  used  for  nutritive 
purposes. 

The  question  whether  oil  can  be  given  in  this 
way  in  sufficiently  large  amounts,  and  also 
whether  it  can  be  utilized  by  the  organism, 
has  been  answered  in  the  affirmative  by  von 
Leube  and  his  pupils.  They  also  found  that, — 
while  proteins,  subcutaneously  injected,  cause 

1  Arthur  Menzel  and  H.  Perso:  Uber  die  Resorption  von  Nahrungs- 
mitteln  vom  Unter-hautzellgewebe  aus.     Wiener  Med.  Wochenschr, 
1869,  p  517. 

2  Von  Leube,  W.:  Uber  klinstliche  Ernahrungs-tberapie.Bd.I,p.490. 


SUBCUTANEOUS  ALIMENTATION         191 

albuminuria,  and  solutions  of  sugar  in  high  con- 
centration cause  various  pains, — olive  oil  may 
be  injected  daily  in  amounts  of  30  to  40  cc.  with- 
out discomfort  to  the  patient. 

In  employing  this  method,  strict  asepsis  must 
be  observed.  Pure  olive  oil  or  sesame  oil, 
previously  sterilized,  can  be  used. 

Mode  of  Procedure. — The  part  of  the  body 
(preferably,  the  thigh)  into  which  the  injection 
is  to  be  made,  is  first  rubbed  off  with  alcohol 
and  then  painted  with  iodine.  A  sterile  glass 
syringe  of  about  15  to  20  cc.,  to  which  a  thin 
rubber  tube  is  attached,  is  connected  with  a 
canula  having  a  large  lumen.  The  syringe  is 
filled  with  the  oil  at  blood  temperature,  and  is 
then  attached  to  the  canula,  so  that  the  oil 
drips  out  of  the  canula.  The  skin  is  then  pierced 
with  the  latter,  and  the  oil  very  slow  y  injected. 
Instead  of  a  syringe,  a  funnel  can  be  used,  and 
the  oil  made  to  run  in  by  its  own  gravity.  The 
oil  should  never  be  injected  too  quickly.  It  is 
best  to  use  ten  to  fifteen  minutes  for  injecting 
10  to  15  cc.  of  oil.  On  removing  the  canula, 
the  wound  is  cleaned  off  with  cotton  and  closed 
with  iodoforai  collodion.  Three  such  injections 
may  be  given  daily. 


192  LECTURES  ON  DIETETICS 

Inasmuch  as  fat  given  as  nourishment  alone, 
without  protein,  increases  the  decomposition  of 
the  nitrogen  content  of  the  body,  it  is  advisable 
when  using  this  method  of  alimentation  to  also 
introduce  some  protein  into  the  organism  by 
some  other  way.  Subcutaneous  alimentation, 
therefore,  will  be  used  principally  as  a  supple- 
mentary procedure,  in  connection  with  some 
other  method  of  nutrition. 

RECTAL  ALIMENTATION 

By  rectal  alimentation  is  understood  the  in- 
gestion  of  nutritive  material  into  the  large  bowel. 
Rectal  alimentation  is  the  oldest  form  of  artifi- 
cial (or  extra-buccal)  nutrition.  This  method 
was  practiced  as  early  as  the  middle  ages,  and 
the  literature  on  this  subject  is  quite  extensive. 
We  need  mention  only  the  names  of  Aetius, 
Hood,  Steinhauser,  Flint,  Ewald,  Filippi,  Albu, 
Leube,Bodenhamer,Stillman,Tyson,Rost,Aldor, 
Edsall  and  Miller,  Eustis,  Benedict,  Adler,  Gomp- 
ertz,  Carter,  and  Goodall. 

The  nutritive  value  of  this  form  of  alimenta- 
tion, especially  with  regard  to  protein  and  fat, 
has  been  found  to  be  quite  small.  Beddard1 

>A.  P.  Beddard:  Rectal  Feeding.  Guy's  Hospital,  October,  1901, 
p.  452. 


RECTAL  ALIMENTATION  193 

thought  that  the  importance  and  value  of  rectal 
alimentation  consisted  chiefly  in  the  amount  of 
water  introduced  into  the  system.  He  says: 
"It  is  quite  sure  that  more  patients  die  on 
account  of  lack  of  water  than  from  lack  of  nour- 
ishment. In  all  cases  of  rectal  alimentation  in 
which  no  water  is  given  by  mouth,  physiologi- 
cal saline  should  be  subcutaneously  injected." 

Wernitz1  likewise  laid  stress  on  the  impor- 
tance of  introducing  more  fluid  into  the  body. 
He  was  the  first  to  recommend  rectal  injections 
of  saline  by  the  drip  method.  He  was  convinced 
that  by  giving  it  slowly  in  this  way  the  fluid  is 
better  absorbed.  In  this  country,  the  rectal 
injection  of  physiological  saline  by  the  drip 
method  has  been  promulgated  by  J.  B.  Murphy, 
of  Chicago.  Deucher,  Eberhard,  Strauss,  Boas, 
and  others,  have  likewise  laid  stress  upon  the 
injection  of  fluids,  and  also  nutritive  material, 
into  the  rectum  slowly  by  the  drip  method. 

Method  of  Administration. — During  the  per- 
iod of  rectal  alimenation,  the  patient  is  best  kept 
in  bed.  Before  administering  the  feeding  enema, 
a  cleansing  injection  (consisting  of  a  quart  of 

1  Wernitz,   J. :   Zur   Behandlung  der  Sepsis.     Correspondenzbl.   f . 
Schweizerrazte,  1903,  p.  41. 
13 


194  LECTURES  ON  DIETETICS 

water  and  a  teaspoonful  of  salt)  should  be  given 
early  in  the  morning,  in  order  to  thoroughly 
evacuate  the  bowel.  One  hour  later,  the  first 
'rectal  alimentation  may  be  administered.  The 
feeding  enema  is  best  injected  by  means  of  a 
fountain  syringe  or  a  Davidson  syringe,  or  a 
plain  hard-rubber  piston  syringe,  and  a  soft- 
rubber  rectal  tube  which  is  introduced  into  the 


niMANM 

FIG.  3 — Einhorn's  rectal  drip  tube. 

anus  for  a  distance  of  about  five  to  seven  inches. 
The  injection  should  be  administered  slowly  and 
without  much  force.  After  the  withdrawal  of 
the  tube  from  the  rectum,  the  patient  is  told  to 
lie  quietly  and  to  endeavor  to  retain  the  enema. 
The  quantity  of  the  feeding  enema  may  be  from 
five  to  ten  ounces.  From  three  to  five  such 
enemata  may  be  given  daily.  All  the  material 
should  be  given  at  blood  temperature. 

For  the  drip  injections,  it  is  best  to  have  some 
warming  apparatus  for  keeping  the  fluid  at  body 
temperature.  Inasmuch  as  the  rectal  tube  for 
the  drip  injection  must  be  kept  in  the  rectum  for 
a  long  while,  a  very  thin  non-collapsible  rubber 


FIG.  4.— Patient  is  being  given  saline  by  the  Murphy  drip  method 
into  the  bowel. 


RECTAL  ALIMENTATION  195 

tube  of  8  to  10  F.  (10  m.m.  circumference)  is 
recommended  for  this  purpose.  At  the  end  of 
the  tube  there  is  a  hard-rubber  or  metal  capsule, 
provided  with  many  openings  (Fig.  3).  This 
thin  tube  does  not  inconvenience  the  patient, 
and  the  capsule  with  the  numerous  openings 
facilitates  the  flow  of  the  material. 

The  following  substances  may  be  used  as  feed- 
ing enemata : 

(a)  Peptone  Enema. — The  different  kinds  of 
peptones  and  propeptones  in  the  market  (Rud- 
isch's    or    Kemmerich's    or    Witte's    peptone, 
somatose,  sanose,  sanatogen),  of  which  about 
one  to  two  ounces  dissolved  in  from  six  to  eight 
ounces  of  water  are  to  be  injected.     The  different 
beef   juices    (Valentine's   beef   juice,    bovinine, 
Mosquera's  beef  jelly,  etc.)  may  be  dissolved  in 
corresponding  quantities. 

(b)  Milk  enema,  250  to  500  c.c.  of  milk  alone, 
or  milk  with  the  addition  of  half  a  gram  of  bicar- 
bonate of  soda. 

(c)  The  Milk  and  Egg  Enemata. — These  are  the 
most  commonly  used.     Their  composition  is  as 
follows:  six  to  seven  ounces  of  milk,  one  or  two 
raw  eggs  well  beaten  up  in  it,  one  teaspoonful  of 
powdered  sugar,  and  one-third  of  a  teaspoonful 


196  LECTURES  ON  DIETETICS 

of  common  table  salt.  Pancreatin  (one  tube  of 
Fairchild's  pancreatin)  may  be  added  to  such  an 
enema,  to  facilitate  its  assimilation. 

(d)  Meat  Pancreas  Enema. — Leube  employs 
enemata  consisting  of  well-chopped  meat  (five 
ounces),  fresh  pancreas  (two  ounces),  one  ounce 
of    fat    (butter), — all   these   ingredients   being 
thoroughly    mixed    with    about   six    ounces   of 
water. 

(e)  Grape  Sugar  Enema. — One  ounce  of  grape 
sugar  in  ten  ounces  of  water  or  physiological 
salt  solution. 

Instead  of  always  using  one  and  the  same 
nourishing  enema,  the  above  combinations  may 
be  alternately  administered. 

In  conjunction  with  these  food  enemata,  injec- 
tions of  water  into  the  bowel  are  made  in  order 
to  increase  the  amount  of  fluid  in  the  system. 
These  injections  of  water  for  absorption  are  of 
great  importance.  They  are  retained  much 
better  if  injected  very  slowly  by  the  so-called 
"Murphy  Drip  Method."  Usually  saline  or 
5-6%  glucose  solution  are  employed,  in  quantities 
varying  from  a  pint  to  a  quart,  which  may  be 
given  twice  a  day. 

The  usual  procedure  is  as  follows: 


RECTAL  ALIMENTATION  197 

7  A.  M.  :     Cleansing  enema. 

8  A.  M.  :     Egg-milk  enema. 

12  M.  :       Drip  enema  of  5  to  10  per  cent 
grape-sugar  solution,  500  cc.  or 
more. 

2  P.  M.  :     Egg-milk  enema. 

6  P.  M.  :     Egg-milk  enema. 

9  P.  M.  :     Same  as  at  12  M. 

Should  the  enemas  cause  diarrhea  opium 
(tinctura  opii,  5  drops)  is  added  to  the  nutritive 
enema,  and  plain  saline  solution  is  substituted 
for  the  grape  sugar  solution. 


LECTURE  XV 
DUODENAL  ALIMENTATION1 

Duodenal  alimentation  means  feeding  a 
patient  through  the  duodenum  in  such  a  manner 
that  the  stomach  is  kept  empty.  This  can  be 
done  by  introducing  a  small  tube  into  the 
the  stomach,  whence  it  passes  of  itself  into  the 
duodenum,  and  is  left  there.  The  main  pur- 
pose of  this  method  is  that  we  should  have  the 
patient  always  ready  for  feeding,  independent  of 
his  desire  to  eat  or  his  aversion  to  food.  It  is 
easily  done.  The  tube  can  even  be  allowed  to 
go  into  the  small  intestine,  depending  upon  the 
length  of  the  tube. 

I  have  practiced  this  method  for  the  last 
ten  years  and  have  treated  500  patients  by  this 
method,  for  periods  varying  from  ten  to  fifteen 
days — most  of  them  from  fourteen  to  fifteen 
days. 

The  food  is  usually  given  every  two  hours, 

1  Delivered  before  the  Clinical  Society  of  the  New  York  Post- 
Graduate  Medical  School  and  Hospital,  March  21,  1913,  and  published 
in  the  Postgraduate,  June,  1913. 

198 


DUODENAL  ALIMENTATION  199 

eight  feedings  a  day.  The  standard  food  is 
milk  (7  to  8  ounces),  one  egg,  and  a  tablespoon- 
ful  of  lactose.  The  lactose  sometimes  causes 
diarrhea  and  should  then  be  omitted.  In  some 
cases  where  it  is  essential  to  see  that  there  is  no 
loss  of  flesh,  butter  (1  to  2  drams)  and  also 
barley  flour  may  be  added  in  every  alternate  or 
in  each  feeding.  This  standard  diet  furnishes 
2215  calories.  If  in  addition,  one  ounce  of  lac- 
tose is  given,  it  brings  it  up  to  about  2695 
calories  for  a  grown  person.  If  butter  is  added, 
it  brings  it  up  to  3000  and  more  calories.  Only 
a  few  patients  cannot  stand  the  milk,  the  latter 
creating  such  a  disturbance  that  it  must  be 
eliminated.  Such  patients  tell  you  that  they 
never  could  take  milk  anyway.  Here  instead  of 
milk,  water  with  barley  or  pea  flour  can  be  sub- 
stituted or  vegetable  milk  employed.  What- 
ever is  fed  to  the  patient  must  be  of  blood 
temperature — neither  cold  nor  hot — strained 
over  a  cloth,  and  it  must  be  given  slowly.  When 
I  began  to  feed  these  patients  I  made  use  of  an 
irrigator,  letting  the  fluid  run  in  by  gravity 
which  would  carry  it  to  the  duodenum,  but  it 
was  soon  found  that  this  was  very  inconvenient. 
The  temperature  cannot  be  so  well  maintained, 


200 


LECTURES  ON  DIETETICS 


and  the  flow  is  either  too  quick  or  too  slow.  It 
was  very  troublesome,  and  the  patients  could 
not  stand  it,  so  a  syringe  was  devised,  pro- 
vided with  a  three-way  stopcock  and  with  a 


FIG.  6. — The  duodenal  feeding  apparatus,  with  table  support. 
A,  tube  leading  to  syringe;  B,  tube  leading  to  duodenal  pump;  C, 
crank;  D,  tube  leading  to  fluid;  F,  fluid;  G,  glass;  T,  table  support  or 
shorter  support.  When  crank  C  is  turned  parallel  to  A,  fluid  can  be 
aspirated  from  the  glass  into  the  syringe.  When  C  is  moved  parallel 
to  B,  the  fluid  from  the  syringe  can  be  emptied  into  the  duodenum. 

little  table  (Fig.  6),  so  that  there  is  no  need  of 
loosening  the  syringe  from  the  tube  each  time 
the  former  has  to  be  filled,  and  the  feeding  can 
be  made  slow  or  fast  as  desired.  The  patients 
usually  prefer  to  have  it  administered  slowly, 


FIG.  5. — Patient  being  fed  through  the  duodenal  tube. 


DUODENAL  ALIMENTATION  201 

for  if  given  quickly  they  feel  uncomfortable.  It 
is  a  very  tedious  performance,  but  the  patients 
can  soon  learn  to  feed  themselves,  and  it  gives 
them  something  to  occupy  themselves  with.  It 
requires  about  twenty  minutes  or  so  for  each 
feeding,  and  that  repeated  for  eight  times  a  day, 
gives  them  something  to  do. 

Instead  of  using  the  syringe  all  this  time 
for  the  injection  of  the  entire  amount  of  nutri- 
ment, this  can  be  advantageously  arranged  after 
Burkhardt  by  syphonage.  Proceed  as  follows: 
Turn  crank  to  A  and  fill  up  the  syringe,  then 
turn  crank  to  B.  and  inject  about  Y*>  of  the 
syringe  into  the  duodenum.  Turn  crank  mid- 
way between  A.  and  B.  parallel  to  the  tube 
connecting  the  table  with  the  nutriment  in  the 
container  and  leave  it  this  way.  The  fluid  after 
having  been  primed  continues  to  run  steadily  by 
syphonage — should  the  flow  stop,  the  syringe  is 
filled  up  again  and  the  process  repeated  as 
described. 

This  way  of  feeding  is  more  agreeable  to  the 
patient  and  less  laborious. 

A  word  in  regard  to  the  technical  points  of  this 
method  of  alimentation .  The  tube  is  put  into  the 
throat  of  the  patient  and  he  swallows  it  with 


202  LECTURES  ON  DIETETICS 

water.  Care  must  be  exercised  that  the  patient 
does  not  swallow  it  too  quickly,  so  that  it  does 
not  rotate  on  itself,  but  will  be  taken  straight 
into  the  stomach.  Then,  a  little  later,  liquid 
food  is  given  by  the  mouth  and  tests  are  made 
from  time  to  time  through  a  syringe  attached  to 
the  tube  to  see  what  can  be  obtained.  If  the 
duodenal  tube  is  still  in  the  stomach  an  acid  liquid 
appears  quite  quickly  by  aspiration.  If  the 
tube  is  beyond  the  pylorus,  in  the  duodenum, 
it  is  very  difficult  to  obtain  fluid,  for  the  duod- 
enum is  usually  empty.  The  secretion  appears 
slowly  in  drops  from  time  to  time  and  shows  an 
alkaline  reaction.  Another  point  of  differenti- 
ation is  that  if  we  should  put  in  air  through  the 
syringe,  the  patient  feels  it  right  away  if  the 
pump  or  tube  is  in  the  stomach;  but  if  the  tube 
end  is  in  the  duodenum  there  is  less  conscious 
sensitiveness  and  the  patient  does  not  feel  the 
air  at  all.  If  we  have  to  deal  with  a  patient  who 
has  no  gastric  secretion  it  is  more  difficult  to 
determine  when  the  pump  has  entered  the  duo- 
denum. Here  there  is  no  acid  in  the  stomach 
anyway,  and  in  order  to  ascertain  whether  the 
pump  is  in  the  stomach  or  duodenum,  we  make 
use  of  different  colored  fluids.  For  instance, 


FIG.  7. — Patient  L.  K.  with  duodenal  tube  in  the  duodenum  with 
empty  stomach.  The  X-ray  photographs  (Figs.  7  and  8)  were 
kindly  made  for  me  by  Dr.  W.  R.  Stewart,  Radiologist  to  the 
Lenox  Hill  Hospital. 


FIG.  8. — Patient  L.  K.  after  the  ingestion  of  a  bismuth  mixture 
into  the  stomach.  The  end  of  the  duodenal  tube  is  distinctly  vis- 
ible outside  of  the  stomach,  in  the  duodenum. 


DUODENAL  ALIMENTATION  203 

a  patient  who  has  had  no  milk,  but  only  bouillon 
or  tea,  may  be  given  a  white  (colored)  fluid,  such 
as  milk.  If  we  then  aspirate  and  obtain  a 
fluid  that  is  not  white,  we  known  that  the  tube 
end  is  beyond  the  stomach.  If  the  patient  had 
milk  we  give  him  black  coffee,  or  any  colored 
fluid  that  is  not  white. 

In  normal  individuals  it  usually  takes  two  or 
three  hours  for  the  tube  to  go  through  into  the 
duodenum,  but  in  cases  where  we  have  to  apply 
this  method,  we  often  have  to  deal  with  a  pyloric 
spasm,  and  then  it  takes  much  longer.  In  some 
cases  I  have  had  to  wait  twenty -four  hours,  the 
longest  time  being  forty-eight  hours.  During 
the  period  of  the  tube  passage,  patient  is  fed  by 
the  mouth  with  liquid  diet  and  tests  are  made 
from  time  to  time  in  order  to  ascertain  the  loca- 
tion of  the  tube. 

On  the  other  hand,  in  cases  of  achylia  gastrica, 
the  passage  of  the  tube  into  the  duodenum  takes 
place  very  quickly.  We  test  it  and  find  it 
sometimes  already  after  5  or  10  minutes  in  the 
duodenum.  The  motility  is  much  greater  there. 
Returning  again  to  the  method  of  feeding: 
The  -temperature  must  be  just  right.  The  food 
introduced  must  be  free  from  thick  particles. 


204  LECTURES  ON  DIETETICS 

All  the  food  should  be  strained,  because  in  pass- 
ing through  the  long  fine  tube  it  would  easily 
become  blocked  if  this  precaution  were  not 
taken.  A  thin  tube  is  better  for  the  patient. 
The  smaller  the  tube,  the  pleasanter  for  the 
patient;  but,  on  the  other  hand,  the  more  difficult 
the  handling  of  it.  Another  rule  is  that  after 
each  feeding,  after  the  food  has  been  given, 
a  little  fluid  should  be  thrown  in  and  then  a  little 
air  when  the  stopcock  is  closed,  in  order  to  keep 
the  tube  always  empty.  If  one  is  not  careful 
to  clean  out  the  tube  with  water  and  air,  the 
end  becomes  clogged  in  a  day  or  two,  and  the 
tube  has  to  be  taken  out  and  replaced,  with  a 
great  deal  of  inconvenience  to  the  patient,  as 
well  as  to  the  doctor  and  nurse,  and  that  tube 
is  often  spoiled.  Where  I  have  patients  under 
my  direct  supervision,  nothing  of  that  kind 
happens.  It  is  simply  faulty  technique  when 
that  occurs 

Another  point  is  that  while  the  patient  has  the 
tube  in,  his  mouth  should  frequently  be  washed 
out  with  some  good  mouth  wash.  If  these 
patients  do  not  eat  anything,  there  is  nothing 
to  cleanse  off  the  surface  of  the  tongue,  and  it  is 
very  essential  that  that  should  be  kept  clean. 


DUODENAL  ALIMENTATION  205 

The  tube  is  left  in  permanently  during  the 
course  of  this  treatment.  Outside  of  the  feeding, 
the  patient  is  given  a  pint  or  more  of  saline 
twice  daily  by  the  duodenal  tube.  The  saline 
may  be  given  either  with  the  syringe  or  by  con- 
necting an  irrigator  to  the  tube.  The  main 
point  is  to  let  the  fluid  run  in  slowly  and  at  the 
right  temperature.  If  the  patient  does  not  like 
that,  it  may  be  given  into  the  rectum  by  the 
Murphy  drip  method,  for  the  bowels  absorb 
saline  very  well.  The  food  is  the  vital  thing. 
By  this  method  we  accomplish  perfect  nutrition 
and  everything  is  utilized. 

In  my  first  patients  I  watched  the  weight  very 
carefully,  and  found  that  in  most  of  them  it  was 
possible  to  keep  them  from  losing  weight.  Some 
of  them  lost,  but  it  was  mainly  due  to  a  loss  of 
water.  They  lost  no  real  flesh,  for  the  nitrogen 
examination  showed  that  under  this  regimen 
they  were  able  to  add  to  their  nitrogen  balance. 
It  is  very  important  to  make  the  patients  gain 
a  little  weight,  but  not  so  necessary  as  to  keep 
them  from  losing  weight.  If  we  want  them  to 
gain,  we  add  a  little  butter  to  the  regimen. 

This  method  of  feeding  keeps  the  stomach 
empty  and  so  gives  it  perfect  rest.  The  princi- 


206  LECTURES  ON  DIETETICS 

pie  of  rest  is  a  very  important  factor  in  curing 
disease,  and  this  is  an  ideal  method  of  accom- 
plishing that  purpose.  A  second  point  is  that 
very  often  it  is  essential  to  accomplish  a  change 
in  the  size  of  the  stomach.  If  it  is  greatly 
dilated,  we  can  keep  it  empty,  and  thus  give  it 
opportunity  to  return  to  its  normal  size.  Still 
another  point  along  the  same  line  comes  up  when 
we  have  to  deal  with  a  dilated  esophagus  due 
to  cardiospasm.  While  the  usual  method  of 
treatment  in  such  cases  is  the  stretching  of  the 
cardia,  in  some  instances  we  find  that  this  alone 
is  not  sufficient,  and  that  everything  remains  in 
the  esophagus.  Here  we  try  to  keep  the  esopha- 
gus empty.  We  must  have  the  food  on  the  other 
side,  and  the  esophagus  and  stomach  are  kept 
empty. 

Another  point  in  the  same  line  is  that  of  saving 
the  organ.  This  method  I  have  recently  applied 
to  the  treatment  of  diseases  of  the  liver,  with 
enlargement  of  that  organ,  and  cirrhosis  of  the 
liver.  The  object  is  to  lessen  the  inflow  of 
blood  to  the  portal  vein.  Everything  that  is 
taken  into  the  stomach  must  pass  through  the 
veins  of  the  stomach  and  then  through  the  portal 
vein  before  it  reaches  the  general  circulation. 


DUODENAL  ALIMENTATION  207 

The  capillaries  in  the  stomach  fill  up  and  the 
veins  carry  the  blood  to  the  liver.  The  same 
occurs  with  the  blood  from  the  duodenum,  the 
esophagus,  etc.  The  fluids  have  to  go  into  the 
portal  vein  and  then  into  the  liver  before  they 
reach  the  general  circulation.  If  the  liver  is 
diseased,  it  is  difficult  for  it  to  take  up  the 
amount  of  blood  and  exert  its  functions  fully. 
If  you  reduce  part  of  the  inflow,  much  saving 
to  the  liver  is  accomplished. 

In  the  large  number  of  patients  whom  I  have 
watched  under  this  method  of  treatment,  the 
results  have  been  very  satisfactory.  One  of  the 
important  advantages  of  this  method  is  that  by 
it  we  are  independent  of  the  will  of  the  patient. 
We  often  have  to  deal  with  conditions  in  which 
nutrition  becomes  extremely  difficult,  extreme 
anorexia,  or  aversion  to  food,  etc.  In  the  case 
of  patients  suffering  from  tuberculosis,  kidney 
trouble,  and  other  conditions,  it  is  most  impor- 
tant to  keep  up  the  nutrition,  and  by  this  method 
the  patient  can  be  fed  independent  of  his  will. 
He  does  not  have  to  eat  anything,  and  he  does 
not  reject  his  food.  Some  time  ago  I  met  a 
physician,  who  was  quite  well  advanced  in  years, 
who  was  suffering  from  chronic  nephritis  and 


208  LECTURES  ON  DIETETICS 

who  could  hardly  partake  of  any  food  on  account 
of  absolute  anorexia.  I  did  not  feel  like  suggest- 
ing this  mode  of  alimentation  to  him,  but  I  gave 
him  one  of  my  reprints  on  the  subject.  He  read 
it,  but  did  not  apply  it,  and  died  about  two  weeks 
later.  If  this  method  of  nutrition  could  have 
been  applied  in  that  instance,  his  life  could 
doubtless  have  been  prolonged. 

This  method  of  treatment  is  applicable: 
First,  in  ulcerations  of  the  stomach  and  duo- 
denum. Even  in  perforated  gastric  ulcer,  duo- 
denal alimentation  is  still  at  times  feasible. 
Dr.  N.  de  Rosas1  has  applied  this  mode  of  treat- 
ment in  a  patient  with  subphrenic  abscess  and 
perforated  gastric  ulcer.  In  this  patient  a 
laparotomy  had  been  performed  and  it  was 
noticed  that  when  the  patient  drank  milk  it 
came  out  through  the  laparotomy  wound. 
When  fed  through  the  duodenum  no  milk 
escaped.  In  two  cases  of  duodenal  perforation 
(fistula)  of  Dr.  Willy  Meyer  and  myself,  2'3 

1  N.  de  Rosas:  Ulcera  del  estomago  perforada  y  abceso  subfrenico 
Revista  Medica  Cubana.  December  1916,  p.  489. 

1  Max  Einhorn :  A  case  of  duodenal  perforation  successfully  treated 
by  duodenal  jejunal)  alimentation,  Med.  Record,  Nov.  30,  1918. 

*  Max  Einhorn :  Duodenal  perforation  (fistula)  treated  by  duodenal 
(jejunal)  alimentation,  another  case,  Journal  American  Med.  Assoc., 
March,  20,  1920. 


DUODENAL  ALIMENTATION  209 

duodenal  alimentation  likewise  effected  a  cure. 
Second,  in  a  great  many  cases  of  dilatation  of  the 
stomach  without  organic  obstruction;  extreme 
atony,  no  matter  whether  there  is  a  pyloric 
spasm  present  or  not.  (In  many  instances  I 
have  found  an  actual  reduction  in  the  size 
of  the  stomach  under  this  treatment.)  Third, 
in  cases  where  nutrition  is  difficult,  nervous 
vomiting,  vomiting  of  pregnancy,  etc.  One 
might  at  first  think  it  would  be  impossible  to 
apply  this  in  such  cases,  for  the  tube  would  be 
vomited,  but  this  is  not  so. 

We  at  first  applied  some  remedies  to  make 
it  possible  for  the  tube  to  remain  in  the  stomach, 
but  as  soon  as  it  got  into  the  duodenum  or 
further  down,  the  vomiting  ceased,  or  the 
patients  only  vomited  something  from  the 
stomach;  as  a  rule,  they  do  not  reject  the  tube. 
In  many  instances  where  there  was  very  severe 
vomiting,  this  method  of  alimentation  has  been 
the  only  feasible  one.  Duodenal  alimentation 
can  also  be  employed  in  disease  of  the  liver, 
and  in  inoperable  cancerous  conditions  of  the 
stomach  or  cardia,  where  the  stomach  is  not 
closed  up  and  the  duodenum  can  be  reached. 


14 


210  LECTURES  ON  DIETETICS 

In  such  conditions  this  method  can  be  applied 
and  bring  comfort  to  the  patient. 

In  one  instance  I  could  not  make  the  diagnosis, 
but  the  patient  had  pains  all  the  time  and  could 
not  retain  any  food.  As  soon  as  this  method  of 
alimentation  was  instituted,  the  pain  ceased,  and 
for  weeks  he  was  free  from  pain  and  was  happy. 
When  the  tube  was  removed,  he  was  examined 
and  found  to  have  a  malignant  disease  of  the 
cardia,  and  later  he  was  operated  upon  and  died 
shortly  after,  but  during  all  his  illness  he  was 
never  so  comfortable  as  during  the  time  that  he 
had  duodenal  alimentation. 


LECTURE  XVI 
INDICATIONS  FOR  ARTIFICIAL  NUTRITION1 

Artificial  or  extrabuccal  nutrition  is  frequently 
resorted  to  in  our  medical  practice.  As  is  well 
known,  we  possess  four  different  methods  of 
artificial  nutrition,  namely:  (1)  subcutaneous 
alimentation;  (2)  esophagogastral  alimentation; 
(3)  duodenal  alimentation;  (4)  rectal  alimentation. 

It  appears  of  interest  to  broach  the  subject  of 
artificial  nutrition  with  regard  to  its  indications 
and  also  the  special  methods  best  suited. 

With  this  object  in  view,  cases  in  which  artifi- 
cial nutrition  may  be  required  can  be  divided 
into  three  groups: 

1.  Cases  of  subnutrition  in  which  the  digestive 
canal  presents  no  obstacles  to  the  passage  of  food. 

2.  Cases  of  difficult  or  impossible  nutrition 
caused  by  obstacles  to  the  passage  of  food  along 
the  digestive  tube. 

3.  Cases  in  which  absolute  rest  of  certain  por- 
tions  of  the   digestive   tract  is   imperative  in 
order  to  effect  a  cure. 

1  American  Journal  of  the  Medical  Sciences,  February,  1915,  p.  165. 

211 


212  LECTURES  ON  DIETETICS 

It  will  be  best  to  discuss  the  above  subject  in 
each  group  separately. 

Group  i.  Subnutrition  with  a  Free  Food 
Passage  along  the  Digestive  Canal.  — Subnutri- 
tion can  be  observed  in  almost  all  acute  and  most 
chronic  diseases.  Ordinarily,  however,  the  physi  - 
cian,  by  rational  instructions  and  an  appropriate 
selection  of  foods,  succeeds  in  introducing  by  the 
usual  way  (per  os)  an  amount  of  aliment  suffi- 
cient for  the  special  case. 

In  rare  cases  the  introduction  of  an  adequate 
amount  of  food  becomes  difficult — if  not  entirely 
impossible — by  a  pronounced  lack  of  appetite 
or  marked  aversion  for  food.  But  even  then 
the  usual  mode  of  nutrition  is  persisted  in,  pro- 
vided the  difficulty  of  food  ingestion  is  merely 
temporary,  i.e.,  lasts  a  few  days.  So  soon, 
however,  as  the  insufficient  nutrition  is  pro- 
tracted, and  attempts  to  overcome  it  by  the 
diverse  means  at  our  disposal  fail,  the  necessity 
of  artificial  nutrition  makes  itself  felt.  In 
complete  abstinence  from  food  artificial  nutrition 
will  be  the  more  demanded. 

As  a  whole,  total  food  abstinence  is  met  with 
principally  in  the  insane  and  melancholies,  also 
in  several  severe  affections  of  the  central  nervous 


ARTIFICIAL  NUTRITION  213 

system,  while  insufficient  nutrition  is  found  in 
chronic  diseases  of  the  most  various  types. 

With  regard  to  the  selection  of  the  special 
kind  of  artificial  nutrition  in  this  group,  the 
esophagogastral  method  will  be  selected.  For 
the  aliment  is  undoubtedly  best  utilized  when 
subjected  to  the  work  of  the  entire  digestive 
apparatus. 

In  case  the  repeated  insertion  of  the  stomach- 
tube  is  especially  annoying  to  the  patient,  the 
duodenal  tube  may  be  used  instead,  provided  the 
patient  is  not  rebellious  to  treatment.  In 
this  instance  the  capsule  at  the  end  of  the  tube 
should  best  be  made  of  gold,  platinum,  or  hard 
rubber.  The  same  method  as  that  of  duodenal 
feeding  is  applied  with  the  difference  that  here 
the  end  of  the  tube  with  the  capsule  may  remain 
in  the  stomach.  The  length  of  the  tube  in  the 
digestive  canal  from  the  lips  should  be  about 
54  cm.  The  duodenal  tube  is,  therefore,  fast- 
ened in  such  a  manner  that  mark  II  is  situated 
outside  the  mouth .  The  thin  tube  does  not  molest 
the  patient  and  is  left  in  the  digestive  tract  for 
about  two  weeks. 

The  food  substances  here  used  are,  likewise, 
identical  with  those  in  duodenal  alimentation, 


214  LECTURES  ON  DIETETICS 

with  the  difference  that  larger  quantities  may 
be  injected  at  each  feeding. 

Whereas  in  absolute  food  abstinence  the  total 
quantity  of  aliment  is  given  through  the  tube, 
in  insufficient  nutrition  one  proceeds  somewhat 
differently.  As  much  food  as  possible  is  admin- 
istered by  the  mouth,  and  what  is  still  lacking  is 
given  by  the  tube.  As  soon  as  the  patient 
ingests  a  sufficient  amount  of  aliment  by  the 
mouth,  artificial  nutrition  is  stopped. 

Group  2.  Difficult  or  Impossible  Nutrition 
Caused  by  Obstacles  to  the  Passage  of  Food 
along  the  Digestive  Tube.  — This  group  repre- 
sents the  largest  number  of  cases  in  which  arti- 
ficial nutrition  is  employed.  It  may  be 
advantageously  split  into  two  subdivisions: 
(a)  Organic  stenosis  of  a  high  degree  (including 
malignant  stricture  even  of  a  minor  degree); 
(6)  medium-sized  benign  organic  stenoses  and 
spastic  strictures. 

(a)  Difficulty  in  the  passage  of  food  caused  by 
marked  stenoses  of  the  esophagus,  cardia,  py- 
lorus, duodenum,  or  small  intestine  demands 
rectal  alimentation.  The  same  obtains  if  the 
difficult  passage  along  the  above  localities  is 
caused  by  pronounced  obstacles  compressing  the 


ARTIFICIAL  NUTRITION  215 

digestive  tube  from  without  or  by  malignant 
stenoses  of  any  degree. 

Similar  stenoses  along  the  colon  require  sub- 
cutaneous alimentation. 

In  all  these  cases  artificial  nutrition  is  but  a 
temporary  adjuvant  and  the  stricture  requires 
separate  treatment,  whenever  possible.  Thus  in 
benign  stenoses,  when  feasible,  stretching  should 
be  performed;  in  malignant  strictures,  or  in 
benign  stenoses  either  not  yielding  or  not  acces- 
sible to  stretching,  likewise  in  tumors  pressing 
from  without  an  operation  for  the  radical  re- 
moval of  the  trouble  should  be  undertaken. 

In  case  the  latter  is  impossible  one  must  be 
satisfied  with  the  surgical  reestablishment  of  a 
food  passage,  making  nutrition  possible.  Thus 
in  obstacles  along  the  esophagus  and  cardia  a 
gastric  fistula,  in  those  of  the  pylorus  and  duo- 
denum a  gastro-enterostomy,  in  those  of  the 
small  intestine  and  colon — according  to  the  loca- 
tion of  the  obstacle — an  entero-enterostomy  or 
enterocolostomy,  or  colocolostomy,  or  ultimately 
an  anus  prceter-naturalis  should  be  established. 

In  case  an  operation  for  some  reason  or  other 
is  unfeasible,  artificial  nutrition  will  naturally 
have  to  be  carried  on  as  long  as  life  persists. 


216  LECTURES  ON  DIETETICS 

In  these  instances  subcutaneous  and  rectal 
alimentation  can  be  to  advantage  conjointly 
employed,  or,  if  necessary,  used  alternately. 

(6)  Medium-sized  Benign  Organic  Stenoses  and 
Spastic  Strictures  of  the  Digestive  Tract. — In 
obstacles  to  the  food  passage  due  either  to  benign 
organic  stenoses  of  a  moderate  degree  or  to 
spastic  conditions — the  selection  of  the  special 
mode  of  nutrition  will  depend  upon  the  location 
of  the  difficulty. 

In  spastic  states  of  the  esophagus  and  cardia— 
provided  they  are  of  such  a  high  degree  that  the 
usual  mode  of  nutrition  be  entirely  impossible— 
and  in  moderate-sized  stenoses  of  the  same 
regions,  gastral  nutrition  by  means  of  a  somewhat 
thin  stomach-tube  will  be  employed.  In  moder- 
ate benign  strictures  of  the  pylorus,  or  duodenum 
or  in  spasm  of  the  pylorus,  duodenal  alimentation 
will  be  resorted  to.  If  the  latter  for  some  reason 
or  other  fails,  rectal  alimentation  will  be  used 
instead. 

Stenoses  of  the  small  intestine — interfering 
with  the  prochoresis  to  such  a  degree  that  com- 
plications endangering  life  begin  to  appear— 
require  rectal  alimentation.  If  the  affected 


ARTIFICIAL  NUTRITION  217 

area  is  situated  in  the  colon,  subcutaneous  ali- 
mentation should  be  instituted. 

In  the  whole  subdivison  (6)  the  separate 
treatment  of  the  principal  lesion  should,  likewise, 
never  be  lost  sight  of.  The  artificial  nutrition 
is  but  a  temporary  adjuvant,  and  should  be 
employed  until  the  obstacles — if  this  be  possible 
— have  been  removed  or  the  natural  mode  of 
nutrition  reestablished. 

Group  3 .  Absolute  Rest  of  Certain  Portions 
of  the  Digestive  Tract  is  Important  in  Order 
to  Effect  a  Cure. — In  this  entire  group  the 
ordinary  way  of  nutrition,  while  at  times  some- 
what impaired,  is,  however,  always  possible. 
The  extrabuccal  alimentation  is  here  employed 
as  a  means  of  curing  or  ameliorating  diseased 
states. 

This  group  may  be  suitably  divided  into  two 
parts:  (a)  diseased  states  of  the  digestive  tract 
proper  (exclusive  of  stenoses) ;  (6)  diseased  states 
of  other  organs  situated  without  the  digestive 
canal. 

(a)  Diseased  States  of  the  Digestive  Tract 
Proper  (Exclusive  of  Stenoses). — Severe  inflam- 
matory processes,  injuries,  and  ulcerations  of 
the  digestive  apparatus  often  demand  perfect 


218  LECTURES  ON  DIETETICS 

rest  of  the  affected  part  in  order  to  achieve 
complete  recovery.  This,  however,  is  possible 
only  then  when  the  food  contact  is  entirely 
removed  from  the  diseased  area. 

If  the  lesions  just  named  involve  the  mouth, 
pharynx,  or  esophagus,  gastral  alimentation  by 
means  of  a  stomach-tube  or  a  thin  tube  a  demeure 
will  be  resorted  to. 

In  case  the  seat  of  the  lesion  is  located  in  the 
stomach  or  duodenum,  duodenal  alimentation 
will  be  employed.  It  is  self-understood  that  in 
affections  of  the  duodenum  the  capsule  end  of 
the  tube  will  have  to  lodge  about  5  to  10  cm.  or 
still  more  below  the  diseased  part.  In  fresh 
hemorrhages  of  the  esophagus,  stomach,  or 
duodenum  rectal  alimentation  is  best  adminis- 
tered during  the  first  two  or  three  days,  and  then 
duodenal  alimentation  instituted.  Ulcers  of  the 
stomach  and  duodenum  have  been  particularly 
benefitted  by  this  mode  of  treatment.  Besides 
in  the  affections  just  mentioned  duodenal  alimen- 
tation can  be  employed  to  great  advantage  in 
the  following  conditions:  dilatation  of  the  stom- 
ach (due  to  weakened  musculature)  and  severe 
neuroses  accompanied  by  persistent  vomiting. 

In  case  the  above  lesions  (described  at  the 


ARTIFICIAL  NUTRITION  219 

beginning  of  this  group)  are  situated  in  the  small 
intestine,  rectal  alimentation  is  employed,  if 
needed — and  if  located  in  the  colon — subcutane- 
ous alimentation.  It  is  self -understood,  however 
that  in  the  last-named  instances  artificial  nutri- 
tion will  be  resorted  to  merely  as  an  extreme 
measure,  for  neither  rectal  nor  subcutaneous  ali- 
mentation, nor  the  two  combined,  are  able  to 
supply  adequate  nutrition  to  the  organism. 

(b)  Diseased  States  of  Other  Organs  Situated 
Without  the  Digestive  Canal. — At  first  sight  it 
appears  rather  strange  that  artificial  nutrition 
should  be  indicated  in  diseases  of  organs  not 
participating  directly  in  the  act  of  digestion. 
If  we  consider,  however,  what  intimate  relations 
exist  between  the  digestive  apparatus  and  the 
organs  of  circulation  as  well  as  of  elimination — 
with  each  ingestion  of  food  there  is  an  overflood- 
ing  of  the  circulation  with  new  material  and  as  a 
consequence  an  augmented  activity  in  the  cir- 
culatory and  eliminative  systems — it  is  plausible 
that  leniency  toward  the  digestive  tract  will 
exert  a  beneficial  influence  on  other  remote 
organs. 

In  fact  it  has  been  long  known  that  a  scanty 
insufficient  nutrition,  as,  for  instance/ 'Karell's 


LECTURES  ON  DIETETICS 

diet,"  applied  for  a  short  period,  is  of  distinct 
benefit  in  disturbed  compensation  of  the  heart. 

Occasionally  the  ingestion  of  the  smallest 
amount  of  food  into  the  stomach  produces  an 
irritative  state  of  the  neighboring  organ,  the 
heart,  especially  if  the  latter  is  badly  diseased. 
In  such  instances  artificial  nutrition  (rectal  or 
duodenal  alimentation)  may  be  indicated. 

In  two  cases  of  severe  myocarditis  causing 
stenocardia  in  a  high  degree — and  in  which  the 
minutest  quantity  of  food  given  by  mouth 
brought  on  attacks  of  severest  dyspnea  greatly 
endangering  life — I  have  seen  duodenal  alimen- 
tation applied  without  the  slightest  inconve- 
nience to  the  patient.  This  mode  of  nutrition 
greatly  alleviated  the  condition  of  the  two 
patients  and  prolonged  their  life. 

There  is,  therefore,  an  indication  for  artificial 
nutrition  in  severe  affections  of  the  heart  in 
which  the  ordinary  mode  of  alimentation  is 
accompanied  by  severe  dangerous  symptoms. 
Rectal  or,  still  better,  duodenal  feeding  will 
then  be  used. 

Diseases  of  the  liver  occasionally  require  a 
course  of  artificial  nutrition  (rectal  or,  still 
better,  duodenal  alimentation),  in  order  to 


ARTIFICIAL  NUTRITION  221 

relieve  somewhat  the  functions  of  this  important 
organ.  In  several  cases  of  cirrhosis  of  the  liver1 
I  have  observed  the  greatly  beneficial  influence 
of  duodenal  alimentation  on  this  disease. 

1  Max  Einhorn:  On  the  Beneficial  Effect  of  Duodenal  Alimentation 
in  Cirrhosis  of  the  Liver,  Medical  Record,  Jiily  26,  1913. 


LECTURE  XVII 


A  few  directions  regarding  the  preparation  of 
food  for  the  sick  appear  to  be  appropriate.  The 
changes  brought  on  artificially  in  raw  food 
material  have  the  following  objects  in  view: 
(1)  cleanliness  and  asepsis;  (2)  increasing  the 
digestibility;  (3)  removal  of  indigestible  or 
inappropriate  material;  (4)  preserving  or  dimin- 
ishing some  of  the  ingredients  contained  in  the 
foods.  All  these  aims  are  accomplished  by 
mechanical,  thermic,  and  chemical  measures 
(washing,  peeling,  pounding,  boiling,  steaming, 
broiling,  frying,  etc.),  which  are  well  known  to 
every  person  accustomed  to  the  kitchen  manage- 
ment for  every  day  life.  For  the  sick  the  same 
principles  prevail.  They  must,  however,  be 
applied  with  greater  precision,  and  with  due 
regard  to  the  special  case.  A  new  feature  here 
is  the  proper  mixing  of  the  food  so  that  the  nutri- 
tive value  is  enhanced,  without  much  change  in 
the  bulk  of  the  aliment. 

222 


PREPARATION  OF  FOOD  FOR  INVALIDS   223 

In  the  following  a  short  description  of  the 
preparation  of  foods  commonly  used  in  the  diet 
of  the  sick  will  be  given.  Simplicity,  cleanliness, 
and  attractiveness  must  form  the  basis  of  each 
dish  furnished  to  the  patient. 

1.  Egg  Albumen  Water. — The  white  of  one 
raw  egg  is  well  beaten  with  about  100  cc.  (6>^ 
to  7  tablespoonfuls)  of  cool  water,  strained  over 
a  piece  of  cheese  cloth  and  seasoned  either  with 
a  trace  of  common  table  salt  or  some  sugar. 

2.  Gruels  or  Decoctions  of  Cereals. — A  heaping 
tablespoonful    of    washed,    prepared    or    pearl 
barley   (rice,  arrowroot,  or  oatmeal)  is  put  into 
a  saucepan  and  a  quart  of  boiling  water  and  a 
pinch  of  salt  added.     Stir  and  boil  until  it  has 
evaporated  to  about  %  of  a  quart,  then  strain 
through  fine  cheese  cloth.     It  can  be  flavored 
with  lemon  rind  while  boiling. 

3.  Almond    Milk. — Thirty    grams.    (§i)    of 
sweet  almonds  and  2  bitter  almonds  are  left  in 
cold  water  over  night  and  peeled.     The  almonds 
are  then  pounded  thoroughly  in  a  mortar  and 
mixed  up  with  half  a  pint  of  warm  water  or  warm 
milk.     The  mixture  is  left  standing  for  £  hours, 
strained  and  pressed  out  well  through  a  piece  of 
cheese  cloth. 


224  LECTURES  ON  DIETETICS 

4.  Meat  Juice   (After  Wiel). — Fat-free  meat 
is  cut  into  cubes  of  3^  inch  each,  wrapped  in 
coarse  linen  and  subjected  to  the  work  of  a  press 
machine.     The  juice  can  be  given  as  it  is  or 
mixed    with   tepid   bouillon.     Valentine's   beef 
juice  is  a  good  ready  preparation  of  meat  juice 
and  can  be  used  instead  of  the  fresh  product,  if 
more  convenient. 

5.  Beef  Juice  (After  Cautley). — (a)  Cut  up 
some  rump  steak  or  undercut  of  the  sirloin  of 
beef  into  pieces  which   will  fit  into   a  lemon 
squeezer.     It  is  better  to  use  a  proper  meat 
press.     Broil  the  meat  rapidly  on  a  hot  fire  or  in 
a  frying  pan,  on  both  sides,  to  keep  in  the  juice. 
Forcibly  express  the  juice  with  slow  pressure. 
Season  with  salt  and  other  condiments  if  neces- 
sary, and  give  it  warm,  in  a  colored  glass  or 
mixed  with  other  foods. 

(6)  Chop  up  finely  or  scrape  with  a  fork  or 
meat  scraper  to  separate  the  connective  tissue, 
lean  beef  and  put  it  in  a  jar  or  cup,  with  a  pinch 
of  salt  and  enough  cold  water  to  cover  it.  Allow 
it  to  stand  from  one  to  six  hours  and  then  squeeze 
well  through  coarse  muslin.  It  may  be  given 
alone  or  mixed  with  other  foods,  warm  or  cold, 


PREPARATION  OF  FOOD  FOR  INVALIDS  225 

but  not  hot.     It  should  be  warmed  by  heating 
in  a  double  boiler. 

6.  Beef -tea. — Half  a  pound  of  fat-free  meat  is 
cut  into  small  cubes  and  put  into  a  fruit  jar  or 
flask  with  wide  opening  and  closed.     Place  the 
vessel   into   warm  water   and  parboil  for  about 
half  an  hour.     Pour  off  the  juice  which  is  ready 
for  use. 

7.  Meat  Broth  or  Bouillon. — One    pound   of 
lean  meat  is  cut  into  small  pieces  and  put  into  a 
pot  containing  about  3  quarts  of  cold  water. 
The  pot  is  well  covered  and  heated  to  boiling 
then  kept  boiling  for  3-4  hours.     A  few  bones 
and  vegetable  herbs  may  be  added  before  boiling 
to  give  the  broth  a  better  taste.     The  broth  is 
poured  off  and  used  clear  without  the  meat. 

8.  Soups    with  Cereals. — Knorr's    barley,  or 
oatmeal,  or  pea  flour  is  stirred  up  first  with  cold 
bouillon  to  a  thin  mass,  then  poured  into  boiling 
meat    broth    and    left    boiling    for    1-2    hours. 
About  one  tablespoonful  of  the  flour  is  enough 
for  one  plate  of  soup.     Before  serving  the  yolk 
of  one  raw  egg  may  be  added  to  the  soup,  which 
increases  the  nutritive  value. 

9.  Kumyss. — Dissolve    y±  of  a  Fleischmann 
yeast  cake  in  about  a  tablespoonful  of  luke- 


ir, 


226  LECTURES  ON  DIETETICS 

warm  water  by  stirring.  Pour  this  into  a  quart 
of  lukewarm  milk,  add  \y%  tablespoonfuls  of 
sugar,  and  shake  thoroughly.  Then  fill  bottles 
with  this  mixture  and  close  them  airtight.  Keep 
them  for  six  hours  in  a  warm  room;  then  put 
them  on  ice,  and  serve  the  following  day. 

10.  Junket. — Heat  half  a  pint  of  milk  in  a  can 
to  body  temperature,  add  1-2  teaspoonfuls  of 
essence  of  pepsin  or  ^  junket  tablet  and  stir 
gently ;  then  let  the  can  stand  in  a  bowl  with  warm 
water  for  about    y2   an  hour,   when  the  milk 
curdles.     Serve  with  sugar  and  nutmeg. 

11.  Whey. — Curdle  milk  in  the  same  manner 
as  in  preparing  junket,  then  strain  through  a 
cheese  cloth.     Serve  cool. 

12.  Milk  Punch. — Two-thirds  of  a  glassful  of 
milk;  one  to  2  teaspoonfuls  of  sugar,  one  raw  egg; 
one  tablespoonful  of  sherry  or  a  K  tablespoonful 
of  brandy;  nutmeg. 

Separate  egg  and  beat  the  yolk  until  very  light 
with  sugar,  add  the  white,  beaten  stiff,  then  the 
brandy  and  the  milk.  Shake  well  and  add  the 
nutmeg.  Serve  hot  or  lukewarm. 

13.  Egg  Nog.  — Beat  the  yolk  of  one  egg,  add 
one  tablespoonful  of  sugar,  and  beat  until  light. 
Add  half  a  glassful  of  milk. 


PREPARATION  OF  FOOD  FOR  INVALIDS   227 

Beat  the  white  of  the  egg  and  fold  it  in  lightly. 
Add  K  a  teaspoonful  of  vanilla,  some  grated 
nutmeg  or  one  tablespoonful  of  lemon  juice. 
Shake  and  serve. 

14.  Custard. — One  pint  scalded  milk,  4  table- 
spoonfuls  sugar,  one  tablespoonful  cornstarch, 
Y±   teaspoonful   salt,   ^    teaspoonful  flavoring, 
one  egg  or  2  yolks. 

Mix  sugar,  cornstarch  and  salt;  add  egg 
slightly  beaten,  then  the  milk,  stirring  constantly. 
Cook  in  double  boiler  until  mixture  thickens 
slightly.  Strain,  cool  and  flavor. 

15.  Junket  Custard. — Take  one  cup  of  tepid 
milk,  add  2  tablespoonfuls  of  sugar  and  Y±  of  a 
junket  tablet  dissolved  in  a  teaspoonful  of  water, 
also   one   teaspoonful  of  brandy.     Shake  well, 
pour  the  mixture  into  moulds  and  let  stand  in  a 
cool  place  until  firm. 

16.  Lemonade    or   Orangeade. — Squeeze  the 
juice  of  half  a  lemon  or  orange;  add  2  tablespoon- 
fuls of  sugar  dissolved  in  a  glassful  of  water. 
Mix  well  and  serve  hot  or  cold. 

17.  Wine  Jelly. — One   ounce  of  gelatin  (%  a 
package),  y%  a  cup  of  cold  water,  2  cups  of  boil- 
ing water,  one  cup  of  wine  (sherry,  port,  claret 


228  LECTURES  ON  DIETETICS 

or  Madeira)  3  tablespoonfuls  of  lemon  juice  and 
a  cup  of  sugar. 

Put  the  gelatin  into  cold  water  and  let  it 
stand  2  minutes.  Add  boiling  water  and  stir  until 
dissolved.  Strain,  add  sugar  and  when  cool  add 
the  wine  and  lemon  juice.  Pour  into  moulds 
and  set  aside  in  a  cool  place  for  several  hours  until 
firm.  Serve  cool. 

18.  Currant  and  Raspberry. —  Pudding  ("Rote 
Grutze"). — One  quart  red  raspberries,  1  quart  red 
currants,  2  cups  cold  water,  !>•£  cups  sugar,  y±  cup 
cornstarch  dissolved  in  cold  water. 

Boil  berries  and  water,  strain  and  add  sugar. 
Let  boil  and  add  three  heaping  tablespoonfuls 
cornstarch  (dissolved  in  cold  water) .  Put  into 
small  moulds  and  keep  in  a  cool  place  until 
firm.  Serve  cool  with  sweet  cream. 

19.  Bread  Soup. — Place  boiling  water  into  a 
plate   (%  full).     Cut  stale  white  bread  (one  or 
two  slices)  into  small  pieces  and  put  them  into 
the  plate.     Add  butter  and  salt.    Let  it  stand 
5-10  minutes  and  serve. 

20.  Oyster  Stew. — Two  cups  scalded  milk,  one 
pint  oysters,  a  little  pepper,  %  a  teaspoonful  of 
salt,  one  tablespoonful  of  butter. 

Put  the  oysters  and  butter  in  a  saucepan  and 


PREPARATION  OP  FOOD  FOR  INVALIDS 

heat  until  the  edges  curl.     Add  the  milk  when  hot 
and  seasoning;  cook  one  minute  and  serve  at  once. 

21.  Clam  broth  can  be  used,  after  boiling  and 
seasoning  same  with  some  pepper  and  salt. 

22.  Clam   Bouillon. — Three-fourths  cup  cold 
water,   %  cup  clam  broth,  %  cup  scalded  milk, 
and  Yz  teaspoonf ul  of  butter.     Salt,  pepper,  celery 
sauce,  white  of  egg  or  whipped  cream. 

Blend  the  water  and  clam  broth,  heat  to  the 
boiling  point;  add  the  scalded  milk  and  the 
butter,  and  stir  well;  season  with  salt,  pepper 
and  celery  sauce.  Add  a  small  quantity  of 
cracker  crumbs  to  thicken  it.  Serve  in  hot 
bouillon  cups  and  garnish  with  two  teaspoonfuls 
of  whipped  cream  or  well-beaten  white  of  egg. 

23.  Calf  s  Brain  Soup. — One  calf's  brain  is  put 
into  cold  water  for  one  hour;  the  water  is  then 
poured  off,  and  the  brain  washed  with  another 
portion  of  water.     The  brain  is  thereupon  boiled 
for  one  hour  either  in  bouillon  or  saltwater  and 
put    through   a   colander.     The   mush   can   be 
diluted  with  bouillon,   boiled  over  again  and 
served.     The  yolk  of  an  egg  mixed  into  it  makes 
a  pleasant  addition  to  this  dish. 

24.  Jellied  Chicken. — Place  chicken  on  fire  as 
for  fricassee;  when  done  remove  skin  and  chop 


230  LECTURES  ON  DIETETICS 

meat  very  fine,  add  liquor  the  chicken  was  boiled 
in,  season  well  and  let  come  to  a  boil.  Take 
about  a  tablespoonful  of  gelatine  soaked  and  two 
tablespoonfuls  of  cream.  Put  in  mold  and  stand 
in  ice  box. 

25.  Milk  Toast. — Toast  several  slices  of  bread 
to  a  delicate  brown.    Then  season  scalding  hot 
milk  with  a  little  salt,  and  pour  it  over  the 
toasted  bread. 

26.  Zwieback  (Meaning  Twice  Baked). — Cut 
white  bread  into  slices  about  >^  an  inch  thick; 
then  bake  them  on  low  fire  until  nicely  brown, 
almost  all  the  way  through.     Keep  in  cool  place. 

Eggs  may  be  eaten  raw  from  the  shell,  cuddled, 
soft  boiled,  poached  or  scrambled  with  butter. 
Hard  boiled  eggs  are  appropriate  in  special 
cases  (hyperchlorhydria  and  hypersecretion) . 

Meats  (chicken,  squab,  lamb,  beef;  fish:  trout, 
pike,  pickerel,  bass,  etc.)  should  always  be  tender. 
They  may  be  served  broiled,  boiled  or  fried  with 
some  butter.  Scraped  beef  is  occasionally  given 
raw,  spread  on  white  bread  or  toast  with  some 
seasoning. 

Measures  to  increase  or  decrease  the  nutritive 
value  of  some  food  articles.  The  nutritive  value 
of  some  food  articles  may  be  increased  by  con- 


PREPARATION  OF  FOOD  FOR  INVALIDS  231 

centration.  Thus  milk  may  be  made  more 
nutritious  by  evaporation  (boiling  down  to  % 
its  bulk).  Again  the  food  value  may  be 
augmented  by  the  incorporation  of  additional 
nutritive  material  into  the  food  articles.  Butter, 
cream,  fats,  oil,  sugar,  honey,  syrup  usually 
serve  this  purpose. 

With  the  same  object  in  view  raw  eggs  and 
also  lactose  are  frequently  added  to  beverages 
and  soups  with  advantage.  In  conditions  in 
which  exclusively  liquid  food  is  indicated  or 
feasible  sufficient  nutrition  is  hardly  possible 
without  these  additions.  The  diet  in  these  cases 
usually  consists  of  milk,  raw  eggs  beaten  up  in 
it  or  in  bouillon,  coffee  with  sugar  and  egg, 
kumyss,  tea  with  sugar  and  milk  or  cream. 
Lactose  can  be  added  to  the  milk  or  to  lemonade 
in  considerable  quantity  (half  an  ounce  to  an 
ounce  of  lactose  to  a  glassful  of  milk  or  lemonade) 
without  interfering  with  the  taste.  Butter  can 
be  added  to  the  eggs  (one  minute  boiled),  and 
cream  to  milk  and  soups,  raising  the  caloric 
value  quite  extensively. 

At  times  it  is  requisite  to  diminish  the  nutritive 
value  of  a  food  article  or  to  prepare  it  in  such  a 


232  LECTURES  ON  DIETETICS 

way  that  some  of  its  special  ingredients  that  are 
not  desirable  should  be  detracted. 

The  nutritive  value  of  many  foods  can  be 
lessened  by  dilution,  or  by  separating  and  taking 
away  some  of  their  ingredients.  Thus  milk 
can  be  diluted  with  water,  or  the  milk  may  be 
skimmed  and  deprived  of  its  usual  content  of 
cream.  Meat  boiled  in  water  will  lose  its  solu- 
ble albumin  and  extractive  matter  (purin  bodies) 
imparting  it  to  the  fluid.  The  latter  becomes 
richer  in  nutritive  material  (soup),  while  the 
meat  is  thereby  impoverished.  Vegetables  when 
steamed  retain  all  their  nutritive  ingredients, 
while  when  boiled  in  water,  lose  part  of  their 
starch  and  mineral  salts. 

These  points  are  utilized  in  the  dietetic  man- 
agement of  the  patients.  In  diabetes,  for 
instance,  green  vegetables  are  thrice  or  twice 
boiled  in  water  and  given  strained  without  the 
fluid,  in  order  to  lessen  the  carbohydrate  content 
of  these  articles.  Again  soup  meat  (the  latter 
boiled  for  quite  a  while  in  plenty  of  water)  may 
be  employed  with  advantage  in  high  blood  pres- 
sure cases,  for  the  meat  is  then  deprived  of  all 
its  extractive  material 


INDEX 


ACCESSORY  foods,  17 
Acetone  bodies  in  urine  in  dia- 
betes,       examination 
for,  132 
tests  for,  137 
test  for  acetone  'J  dies  in  urine 

in  diabetes,  137 
Achylia     gastrica      complicating 

diabetes,  116 
diarrhea  from,  102,  103 
diet  in,  76 

Acidosis,  111,  120,  128 
Air,  fresh,  92 
Albumin,  17 

daily  requirement  of,  16 
egg  water,  223 
functions  of,  18 
Alcohol,  17 

in  diabetes,  125,  130 
Alcoholic  beverages,  17 
Alimentary  tract,  operations  on, 

diet  in,  186 
Alimentation,  158 
duodenal,  198 

in  operations  on  alimentary 

tract,  186 

indications  for,  208 
technical  points  of,  201 
rectal,  192 

in  operations  on  alimentary 

tract,  186 
in  uremia,  165 
method,  193 
subcutaneous,  189 


Alkali  treatment  in  diabetes,  128 
Alkaloid  beverages,  17 
Alkaloidal  substances,  17 
Allen  on  diabetes,  122 
Allen's    plan    of    treatment    of 

diabetes,  124 
Almond  milk,  223 
Amylaceous  dyspepsia,  67 
Anesthesia,  diet  after,  184 
as  influenced  by,  184 
preparatory  dietetic  regime  for, 

183 
Animal    diet,    disadvantages    of, 

111 

intermediate,  112 
strict,  111 

food,  residue  left,  32 
vs.  vegetable  diet,  14 
Antineuritic  vitamine,  16 
Antirachitic  vitamine,  16 
Antiscorbutic  vitamine,  16 
Appetite,  effect  of  fatigue  on,  90 
Arteriosclerosis,     Schroth's     diet 

in,  173 

Artificial    nutrition    in    difficult 
or     impossible     nutrition 
caused    by    obstacles    to 
passage     of     food     along 
digestive  tube,  214 
in    subnutrition    with    free 
food  passage  along  diges- 
tive canal,  211 
indications  for,  211 
methods,  211 


233 


234 


INDEX 


Artificial  nutrition  when  absolute 
rest  of  certain  portions  of 
digestive  tract  is  impor- 
tant, to  effect  a  cure, 
217 
Artificially  fed  infant,  daily 

caloric  requirements  of,  21 
Ascites,  Karell's  milk  diet  in,  175 

Schroth's  diet  in,  178 
Assimilation  of  food,  91 
aids  to,  92 

BANTING'S  regime,  170 
Beaumont    on     digestibility     of 

foods,  30 
Beddard  on  rectal  alimentation, 

192-193 
Beef  juice,  224 
Beef-tea,  225 
Benedict  test  for  sugar  in  urine, 

in  diabetes,  133 
Bessau    and    Schmid's    table    of 

purin  content  of  common  foods, 

151 
Beverages,  alcoholic,  17 

alkaloid,  17 

composition  of,  26 

purin  content  of,  153 
Bickel's  food  groups  distinguish- 
ing between  weak  and  strong 

secretory  stimulants,  68 
Bismuth  for  diarrhea,  57 
Blood,    uric    acid    in,    in    gout, 

147,  149 
Blood-pressure,    high,   purin-free 

diet  for,  178 
Bouchardat     and     Cantani     on 

diabetes,  121 
Boullion,  225 

clam,  229 

Bowels,  diseases  of,  diet  in,  59 
Bread  soup,  228 
Breads,  purin  content  of,  153 


Bright's  disease,  diet  for,  57 
Broth,  clam,  220 

meat,  225 
Building  up,  in  cases  of  achylia 

gastrica,  81-83 
Bulkley's  rice,  bread,  butter  and 

water  r6gime,  173 
Butter  for  building  up  in  cases  of 

achylia  gastrica,  81-83 

CAFFEIN,  17 

Calf's  brain  soup,  229 

Caloric  value  of  foods,  19 

of  Soldier's  food  ration,  22 
Calorie,  definition  of,  19 
great,  19 
small,  19 

Calories,  daily  requirement,  20 
Cancer  of  stomach,  diet  for,  61 
Cantani  and  Bouchardat  on 

diabetes,  121 
Carbohydrate,  17 

daily  requirement  of,  16 
Carbohydrates,  15 
Care  of  digestion,  86 

for  soldiers,  94 
Catarrh,    gastric,    chronic,    diet 

in,  75 
of    small    intestines,    diarrhea 

from,  105 

of  stomach   complicating   dia- 
betes, 118 

Cereals,  composition  of,  25 
decoctions  of,  223 
purin  content  of,  153 
soups  with,  225 
Cheese,  purin  content  of,  152 
Chicken,  jellied,  229 
Chronic  diseases,  diet  in,  54 
interstitial   nephritis,    diet   in, 

162 

parenchymatous  nephritis,  diet 
in,  160 


INDEX 


235 


Cirrhosis    hepatis,    milk    regime 
in,  174 

Clam  bouillon,  229 
broth,  229 

Classification  of  food,  15,  16 

Codein  for  diarrhea,  57 

Coleman,  Dr.  Warren,  on  nourish- 
ment of  typhoid  patients,   51 

Colon,  operations  on,  diet  in,  188 

Condiments,  17 

Congestive  nephritis,  diet  in,  164 

Consciousness,  loss  of,  in  uremia, 
rectal  alimentation  in,  165 

Constipation  with  obesity,  Hoff- 
mann's regime  in,  174 

Continuous  hypersecretion,   diet 
in,  73 

Convalescents,  diet  for,  178 

Corpulency,  84 

Cow's  milk,   nutritive  value   of, 
table  showing,  180 

Cream,  nutritive  value  of,  table 
showing,  180 

Cucumbers  in  dropsy,  168 

Currant  and  raspberry  pudding, 
228 

Custard,  227 
junket,  227 

DAIRY  products,  composition  of, 23 
Death,  93 

Decoctions  of  cereals,  223 
Defecation,  92 

Diabetes,   achylia  gastrica   com- 
plicating, 116 
alcohol  in,  125 
alkali  treatment  in,  128 
Allen's  treatment,  124 
catarrh  of  stomach  complicat- 
ing, 118 

examination    of    urine   in,    for 
sugar  and  acetone,  132 


Diabetes,  exercise  in,  125 

fast  days  in,  121,  122 

freedom    from    glycosuria    in, 
128 

green  vegetables  in,  121 

hyperchlorhydria       complicat- 
ing, 116 

Joslin's    table    of    foods    for, 

137,  138 

Diabetes  mellitus,  110 
diet  for,  58 

Einhorn's  diet  for,  114 
intermediate  diet,  112 
meat  and  fat  diet,  111 
Seegen's  diet  for,  112 
strict  diet,  111 
Von  Noorden  on,  112 

metabolism  in,  120 

reduction  in  weight  in,  129 

regime  for,  130 

sugar  freedom  in,  123,  124 

table  of  foods  frequently  used 
in,  139 

with    stomach    complications, 

116 
Diacetic   acid    test   for   acetone 

bodies    in   urine   in   diabetes, 

137 

Diarrhea,  chronic,   dietetic  treat- 
ment of,  99 

from     achylia     gastrica,     102, 
103 

from    catarrh   of   small   intes- 
tines, 105 

from  chronic  intestinal  obstruc- 
tion, 100 

from   enema,    opium   for,    197 

from     hyperchlorhydria,     103, 
105 

from  stomach  disturbances,  102 

nervous,  100 

severe,  diet  in,  60 


236 


INDEX 


Diet,   animal  vs.  vegetable,  14 
as  influenced  by  anesthesia,  184 

by  nature  of  operation  and 

organ  involved,  185 
dry,  Schroth's,  172 
fluid,  for  hospital  patients,  182 

without  nutritive  value,  176 
for  convalescents,  178 
for  intestinal  putrefaction,  179 
for  patients  entering  hospital, 

180,  182 

for  tuberculosis,  55 
full,  for  hospital  patients,  182 
in  acute  diseases  of  prolonged 

duration,  48 

in  chronic  affections  not  accom- 
panied by  fever,  54 
in  complications  of  kidneys,  164 
in  disease,  40 

of  kidneys,  157 
in  health,  35,  88,  89 
in    operations    on    alimentary 

tract,  186 

in  operative  cases,  183 
in  typhoid  fever,  48 
kitchen,  222 
liquid,  175 
principles  of,  11 
purin-free,  178 
regimes,  169 

soft,  for  hospital  patients,  182 
soup,  175 
vegetable  milk,  179 

vs.  animal,  14 
Digestibility  of  foods,  30 
Digestion,  86 
act  of,  91 
care  of,  86 

for  soldier,  94 
defecation,  97 
food  problem  in,  95 
rest  in,  97 


Digestion,    care   of,    for   soldiers, 

rules  for  meals,  95 
sleep,  97 
urination,  97 
effect  of  fatigue  on,  90 
final  act  of,  92 
in  stomach,  31 
residue  after,  32 
time  required,  31,  32 
Digestive  hypersecretion,  66 
tract,   diseases  of,   acute,   diet 

in,  59 

chronic,  diet  in,  60 
irritative  conditions  of,  milk 

regime  in,  174 
Disease,  diet  in,  40 
Diseased  states  of  digestive  tract 
(exclusive  of  stenoses)  arti- 
ficial nutrition  in,  217 
of  organs  without  digestive 
canal,    artificial    nutrition 
in,  219 
Diseases,     acute,     of    prolonged 

duration,  diet  in,  48 
of  kidneys,  diet  in,  157 
Drip  method,  rectal  injections  of 
fluid  by,114,115, 165,184,193 
tube,  rectal,  Einhorn's,  194 
Dropsy  in  nephritis,  diet  in,  165 
Kakowski's  dietary  regime  for, 

167 

Dry  diet,  Schroth's,  172 
Duodenal  alimentation,  198 
apparatus  for,  200 
in  operations  on  alimentary 

tract,  186 
indications  for,  208 
technical  points  of,  201 
Dyspepsia,  amylaceous,  67 
diet  for,  61 
nervous,  diet  in,  74 
starchy,  67 


INDEX 


237 


EATING,  fast  vs.  slowly,  36,  37 

faulty  habits  of,  87 

frequency  of,  38 

frequent,  in  continuous  hyper- 
secretion,  73,  74 

proper,  90,  91 

Ebstein-Banting  regime,  171 
Eczema,  Bulkley's  diet  in,  174 
Edema  in  nephritis,  diet  for,  166 

Karell's  milk  diet  in,  175 

Schroth's  diet  in,  173 
Egg  albumin  water,  223 

and  milk  enema,  195 
Egg-nog,  226 

Eggs,  purin  content  of,  152 
Einhorn's  diet  for  diabetes  mel- 
litus,  114 

fermentation       saccharometer, 
134 

rectal  drip  tube,  194 
Eliminative  systems,  91 
Endogenous  uric  acid,  149 
Enema,    diarrhea    from,    opium 
for,  197 

egg  and  milk,  195 

feeding,  195 

grape  sugar,  196 

meat  pancreas,  196 

milk,  195 

peptone,  195 
Enteritis,    chronic,    milk    regime 

in,  174 
Erythema,     Bulkley's     diet     in, 

174 
Esophagus,    operations   on,    diet 

in,  186 
Exercise,  92 

for  stout  persons,  84 

in  diabetes,  125 
Exogenous  uric  acid,  149 
Extrabuccal     nutrition,     indica- 
tions for,  211 


FAST  eating,  36,  37 

Fasting  in  treatment  of  diabetes, 

121,  122 
Fat,  15,  17 

content   of   animal   foods   and 

their  digestibility,  33 
daily  requirement  of,  17 
functions  of,  18 
soluble  A  vitamine,  16 
Fatigue,  effect  of,  on  appetite,  90 

on  digestion,  90 
Fat-proteid  regime,  170 
Fats,  15 

in   continuous   hypersecretion, 

74 

in  hyperchlorhydria,  74 
Fear  of  food,  64 

Feeding.     See  also  Alimentation. 
duodenal,  apparatus  for,  200 
enema,  195 
Fermentation         saccharometer, 

Einhorn's,  134 

test  for  sugar  in  urine  in  dia- 
betes, 134 

Fischer's  vegetable  milk  diet,  179 
Fish,  composition  of,  24 
purin  content  of,  152 
Fluid  diet,  full  (full  ration),  177 
medium  (half  ration),  177 
with  low  nutritive  value,  176 
without  nutritive  value,  176 
Fluids  in  system,   necessity  for, 

42,  43,  46 
Flushing     system     with     fluids 

(water)  in  gout,  151 
Food,  accessory,  17 
amount  required,  14 
assimilation  of,  91 

aids  to,  92 
caloric  values  of,  19 
calories,  19 
components  of,  21 


238 


INDEX 


Food,      composition     of     most 

common,  23-27 
digestibility  of,  30 
elementary  classification  of, 

15,  16 

elements,    average   daily   con- 
sumption of,  16 
estimating  heat  values  of,  19 
fear  of,  64 

for  invalids,  preparation  of,  222 
in  duodenal  alimentation,  199 
nutritive  value  of,  measures  to 

increase  or  decrease,  230 
purin  content  of,  151 
quantity  of,  required,  86,  88 
in  growth,   manhood,   old 

age,  86 

sufficient  intake,  guides  to,  88 
tables,  23-27 
values  in  household  measures, 

27 
what  kinds  should   be  taken, 

88,  89 

Frequency  of  eating,  38 
Frequent    eating    in    continuous 

hypersecretion,  73,  74 
Fresh  air,  92 

Fruits,  composition  of,  26 
leguminous,  purin  content  of, 

153 

purin  content  of,  152 
Full  fiuid  diet  (full  ration),  177 
Functional    diseases   of   stomach 

and  intestines,  diet  for,  66 
nervous  disorders,  diet  in,  75 

GAME,  composition  of,  24 

Garrod  on  gout,  147 

Gastric    catarrh,    chronic,    diet 

in,  75 
Glucose    solution    injections,    by 

Murphy  drip  method,  196 


Glucose   solution    injections,   by 
Murphy     drip     method,      in 
uremia,  165 
Glycosuria,     freedom     from,     in 

diabetes,  128 
Gout,  acute,  diet  in,  154 
chronic,  diet  in,  155 
diet  for,  57,  147 
flushing     system     with     fluids 

(water)  in,  151 
massage  in,  151 
purin  metabolism  in,  148,  150 
purin-free  diet  in,  149,  150,  151 
relation  of  uric  acid  to,  147 
Grape  sugar  enema,  196 
Grapefruit  in  typhoid  fever,  54 
Graves  on  diet  for  typhoid  fever,  48 
Grouping  foods  by  physical  char- 
acteristics, 33,  34 
Gruels,  223 
Guelpa  on  diabetes,  122 

HEALTH,  diet  in,  35,  88,  89 
Heart,     affections     of,     Karell's 

milk  diet  in,  175 
Heat,  18 

units,  19 

values  of  food,  estimating,  19 
Hoffmann's  regime,  174 
Hospital,  patients  entering,  diets 

for,  180,  182 

Hyperacidity  of  stomach,  66 
Hyperchlorhydria      complicating 
diabetes,  116 

diarrhea  from,  103,  105 

diet  for,  67 
Hypernutrition,  88 
Hypersecretion,  continuous,  diet 
in,  73 

digestive,  66 

Hypoacidity  of  stomach,  66 
diet  in,  75 


INDEX 


239 


INANITION,  57,  81 
Indications    for    artificial    nutri- 
tion, 211 

for  duodenal  feeding,  208 
Indigestion,  acute,  diet  in,  59 
Infant,     artificially     fed,     daily 

caloric  requirements  of,  21 
caloric  requirements  of,  21 
Injections  of  glucose  solution  by 
Murphy         drip 
method,  196 
in  uremia,  165 
saline,  46 
subcutaneous,  46 
Interstitial     nephritis,     chronic, 

diet  in,  162 
Intestinal  digestion,  31 

obstruction,   chronic,   diarrhea 

from,  100 

putrefaction,  diet  for,  179 
Intestines,     small,     catarrh     of, 

diarrhea  from,  105 
Invalids,    food    for,    preparation 

of,  222 

Itching   of   skin,    Bulkley's   diet 
in,  174 

JELLIED  chicken,  229 

Jelly,  wine,  227 

Joslin  on  diabetes,  123 

Joslin's   table   of  foods   for   dia- 
betics, 137,  138 

Juice,  beef,  224 
meat,  224 

Junket,  226 
custard,  227 

KAKOWSKI'B  dietary   regime  for 

dropsy,  167 
Karens  milk  diet,  175 
Ketones  in  urine  in  diabetes,  tests 

for,  137 


Kidney    complications,    diet    in, 

164 

troubles,  diet  for,  57,  58 
Kidneys,  acute  affections  of,  diet 

in,  159 

affections    of,    groups    of,    159 
KarelPs  milk  diet  in,  175 
milk  regime  in,  174 
chronic  affections  of,   diet  in, 

160 

diseases  of,  diet  in,  157 
disturbances     of,     phenomena 

in,  157 

function  of,  157 
Kitchen,  diet,  222 
Kumyss,  225 

LEGUMINOUS   fruits,    purin    con- 
tent of,  153 
Lemonade,  227 

in  typhoid  fever,  54 
Leyden's  theory  on  typhoid  nour- 
ishment, 51 
Life,  93 

origin  of,  13 
Liquid  diet,  175 
Liquids,   importance   of,   in   diet 

for  disease,  42,  43 
in  acute  diseases,  44 
necessity    of    giving,    in    dis- 
ease, 46 

MASSAGE  in  gout,  151 
Measures  to  increase  or  decrease 

nutritive  value  of  food  articles, 

230 
Meat  broth,  225 

juice,  224 

pancreas  enema,  196 
Meats,  composition  of,  24 

in  diet,  89 

purin  content  of,  151 


240 


INDEX 


Medium  fluid  diet  (half  ration), 

177 

Melons  in  dropsy,  168 
Menzel  and  Perso,   introduction 
of   subcutaneous   alimentation 
by,  190 
Metabolism  in  diabetes,  120 

purin,  in  gout,  148,  150 
Milk,  almond,  223 
and  egg  enema,  195 
cow's,  nutritive  value  of,  table 

showing,  180 

cure    of    Winternitz    for    dia- 
betes, 114,  115 
diet,  Karell's,  175 
enema,  195 

in  dietary  of  typhoid  fever,  49 
punch,  223 
purin  content  of,  152 
regime,  174 
toast,  230 
vegetable,  diet,  179 
nutritive     value     of,     table 

showing,  180 
Mosse's  potato  cure  for  diabetes, 

114,  115 
Murphy  drip,  glucose  solution  by, 

in  uremia,  165 
rectal  injections  of  fluid  by, 

114,  115,  193 
saline     solution     by,     after 

anesthesia,  184 

Mushrooms,    purin    content    of, 
152 

NATURE  as  guide  to  appetite,  41 
Naunyn  on  diabetes,  121 
Nephritis,  acute,  diet  in,  159 

chronic   parenchymatous,   diet 
in,  160 

congestive,  diet  in,  164 

diet  in,  158 


Nephritis,     interstitial,    chronic, 

diet  in,  162 

salt  retention  in,  diet  in,  166 
salt-free  diet  in,  166 
Nervous  diarrhea,  100 

disorders,  functional,  diet  in,  75 
dyspepsia,  diet  in,  74 
Neuralgias,  obstinate,  Hoffmann's 

regime  in,  174 
severe,   Karell's  milk  diet  in, 

175 

Newborn,   daily   caloric   require- 
ments of,  21 
Nourishment         for         typhoid 

patients,  48-54 
in  chronic  diseases,  54 
Nutrition,    artificial,    in   difficult 
or     impossible     nutrition 
caused    by     obstacles    to 
passage     of     food     along 
digestive  tube,  214 
in    subnutrition    with     free 
food  passage  along  diges- 
tive canal,  21 1 
indications  for,  211 
methods,  211 

when  absolute  rest  of  certain 
portions  of  digestive  tract 
is  important  to  effect  a 
cure,  217 

difficult  or  impossible,  caused 
by   obstacles   to  passage   of 
food    along    digestive    tube, 
artificial  nutrition  in,  214 
extrahuccal,  indications  for,  211 
principles  of,  11 
too  scanty,  87 

Nutritive  value,  fluid  diet  with- 
out, 176 

low,  fluid  diet  with,  176 
of  food  articles,  measures  to 
increase  or  decrease,  230 


INDEX 


241 


Nutritive  value  of  vegetable  milk, 
cow's  milk,  and  cream,  table 
showing,  180 

OATMEAL  cure  of  Von  Noorden  for 

diabetes,  114,  115,  117 
Obesity  with  constipation,  Hoff- 
mann's regime  in,  174 
Obstinate  neuralgias,  Hoffmann's 

regime  in,  174 
Obstruction,    intestinal,   chronic, 

diarrhea  from,  100 
Oertel-Banting  regime,  172 
Oil,  subcutaneous  injection  of,  190 

method,  191 
Olive  oil,  subcutaneous  injection 

of,  190 
method,  191 

Operation   and    organ    involved, 
influence  of,  on  diet,  185 

on    alimentary   tract,   diet  in, 

186 

Operative  cases,  diet  in,  183 
Opium  for  diarrhea  from  enema, 

197 

Orangeade,  227 
Organic  diseases,  diet  for,  60 
Overeating,  87 
Oyster  stew,  228 

PANCREAS,  meat  enema,  196 
Parenchymatous       nephritis, 

chronic,  diet  in,  160 
Patients  entering  hospital,  diets 

for,  180,  182 

Pawlow  on  hyperchlorhydria,  68 
Peptone  enema,  195 
Perso  and  Menzel,  introduction  of 

subcutaneous  alimentation  by, 

190 
Phenomena    in    disturbances    of 

kidneys,  157 
16 


Physical  characteristics  of  foods 

and  their  digestibility,  33 
Potato   cure   of   Mosse   for   dia- 
betes, 114,  115 
Proteid-fat  regime,  170 
Protein,  functions  of,  18 
in     connection     with     subcu- 
taneous injection  of  oil,  192 
necessity  for,  17,  18 
Proteins,  15 
Pudding,  currant  and  raspberry, 

228 

Punch,  milk,  226 
Purin  content  of  common  foods, 

151 
metabolism      in      gout,      148, 

150 
Purin-free  diet,  178 

for  chronic  gout,  155 
in  gout,  149,  150,  151 
Putrefaction,  intestinal,  diet  for, 
179 

QUANTITATIVE  ammonia  test  for 
acetone  bodies  in  urine  in 
diabetes,  137 

RASPBERRY    and    currant    pud- 
ding, 228 
Rectal  alimentation,  192 

in  operations  on  alimentary 

tract,  186 
in  uremia,  165 
method,  193 

drip  tube,  Einhorn's,  194 
Rectum  and  vagina,  plastic  oper- 
ations    between,    diet    in, 
188 

operations  on,  diet  in,  188 
saline  solution,  by  Murphy  drip 
through,  after  anesthesia,  184 


INDEX 


Reducing  flesh,  exercise  for,  84 
Regime,  Banting's,  170 

Bulkley's  restricted,  173 

Ebstein-Banting,  171 

Hoffmann's,  174 

Kakowski's  for  dropsy,  167 

milk,  174 

Oertel-Banting,  172 

proteid-fat,  170 

squash,  in  dropsy,  167 

superalimentation,  169 

vegetarian  diet,  172 
Residue  after  digestion,  32 
Rest,  92 
Rheumatism,    chronic,    diet   for, 

57 
Rosenheim,     Prof.,    on    chronic 

diarrhea,  106 
Rote  griitze,  228 

SACCHAROMETER,  fermentation, 
Einhorn's,  134 

Saline  solution  injections,  46 

by  Murphy  drip  method, 

196 
after  anesthesia,  184 

Salisbury  regime,  67 

Salt  retention  in  nephritis,  diet 
in,  166 

Salt-free  diet  in  nephritis,  166 

Schmid  and  Bessau's  table  of 
purin  content  of  common  foods, 
151 

Schroth's  dry  diet,  172 

Seegen's  diet  for  diabetes,  112 

Sesame  oil,  subcutaneous  injec- 
tion of,  191 

Sitophobia,  64 

Skin,  itching  of,  Bulkley's  diet 
in,  174 

Sleep,  92 

Slow  eating,  36 


Soldiers,  care  of  digestion  for,  94 
defecation,  97 
food  problem  in,  95 
rest,  97 

rules  for  meals.  95 
sleep,  97 
urination,  97 
food    ration,  caloric   value  of, 

22 

Soup,  bread,  228 
calf's  brain,  229 
diet,  175 
Soups,  composition  of,  26 

with  cereals,  225 
Squash  regime  in  dropsy,  167 
Starch,  action  of,  in  hyperacidity, 

72 
Starch-free    diet    in    hyperchlor- 

hydria,  68 

Starchy  dyspepsia,  67 
Starvation    method    in    typhoid 

fever,  48 

Stenoses  and  spastic  strictures  of 
digestive  tract,  artificial  nu- 
trition in,  216 

organic,   of  high   degree,   arti- 
ficial nutrition  in,  214 
Stew,  oyster,  228 
Stomach,  cancer  of,  diet  for,  61 
catarrh   of,    complicating   dia- 
betes, 118 

complications  with  diabetes,  113 
digestion  in,  31 
operations  on,  diet  in,  186 
ulcer  of,  diet  in,  60 
Strauss  and  Widal  on  salt  reten- 
tion in  nephritis,  166 
Strictures,  spastic,  and  stenoses 
of     digestive     tract,     artificial 
nutrition  in,  216 

Subcutaneous   alimentation,    189 
injections,  46 


INDEX 


243 


Subcutaneous    injections    of    oil, 

190 

method,  191 
Subnutrition,  88 

in  chronic  diseases,  56 
with  free  food,  passage  along 
digestive  canal,  artificial 
nutrition  in,  212 
Sugar  disease,  diet  for,  58 
freedom  in  diabetes,  123,  124 
grape  enema,  196 
in  urine,  in  diabetes,  Benedict 

test  for,  133 
examination  for,  132 
fermentation  test  for,  134 
Superalimentation  regime,  169 

TANNIGEN  for  diarrhea,  57 
Tannin-agar  for  diarrhea,  108 
Theobromin,  17 
Thin  people  made  stouter,  82 
Toast,  milk,  230 
Trimethylxanthin,  17 
Tuberculosis,  diet  for,  55 
Typhoid  fever,  diet  in,  48 

Dr.  Warren  Coleman's 
theory  of  nourishment, 
51 

Graves'  treatment,  48 
Leyden's  theory  of  nourish- 
ment, 51 
milk  diet  for,  49 
nourishment  for,  48—54 
solid     and     semi-solid     diet 

for,  50,  51 
starvation  in,  48 

ULCER  of  stomach,  diet  in,  60 
Ulcus    ventriculi,     milk    regime 

in,  174 
Uremia,  diet  in,  164 


Uremia,    glucose    solution  by 

Murphy  drip  in,  165 

rectal  alimentation  hi,  165 

Uric  acid  deposits  in  gout,  147 

in  blood  in  gout,  147,  149 
endogenous,  149 
exogenous,  149 
relation  of,  to  gout,  147 
Uricemia,  149 

Urine,  acetone  bodies  in,  in  dia- 
betes, tests  for,  137 
examination  of,  in  diabetes,  for 

sugar  and  acetone,  132 
sugar  in,  in  diabetes,  Benedict 

test  for,  133 
fermentation  test  for,  134 

VAGINA     and     rectum,     plastic 

operations    between,    diet    in, 

188 
Vegetable  milk  diet,  179 

nutritive     value     of,     table 
showing,  180 

vs.  animal  diet,  14 
Vegetables,  composition  of,  25 

purin  content  of,  152 
Vegetarian  diet  regime,  172 
Vitamines,  15 

fat  soluble  A,  16 

varieties  of,  16 

water  soluble  B,  16 

water  soluble  C,  16 
Vomiting  in   uremia,   rectal  ali- 
mentation for,  165 
von    Leube,    improvement    and 

promulgation  of  subcutaneous 

alimentation  by,  190 
Von  Noorden  on  diabetes,  122 

on  diet  for  diabetes,  112 
Von  Noorden's  oatmeal  cure  for 

diabetes,  114,  115,  117 


244 


INDEX 


WASTE,  elimination  of,  91,  92 
Water,  17 

benefits     of     flushing     system 

with,  42,  43,  44,  46 
in  gout,  151 

daily  requirement  of,  16 
egg  albumen,  223 
importance  of,  42,  89,  90 
injections  of,  by  Murphy  drip 

method,  196 
soluble  B  vitamine,  16 

C  vitamine,  16 
Weight,  increasing,  81-83 


Weight,  reducing,  84,  85 

reduction    in,    in    diabetes. 
129 

Wernitz  on  importance  of  rectal 
injections  of  fluid,  193 

Whey,  226 

Widal  and  Strauss  on  salt  reten- 
tion in  nephritis,  166 

Wine  jelly,  227 

Winternitz's  milk  cure  for  dia- 
betes, 114,  115 

ZWIEBACK,  230 


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